Science.gov

Sample records for pediatric cardiac postoperative

  1. Importance of pre- and postoperative physiotherapy in pediatric cardiac surgery.

    PubMed

    Cavenaghi, Simone; Moura, Silvia Cristina Garcia de; Silva, Thalis Henrique da; Venturinelli, Talita Daniela; Marino, Lais Helena Carvalho; Lamari, Neuseli Marino

    2009-01-01

    Lung complications during postoperative of pediatric heart surgery are frequently highlighting atelectasis and pneumonia. Physiotherapy has an important role in the treatment of these complications. We reviewed and update the physiotherapy performance in the preoperative and in the postoperative lung complication of pediatric cardiac surgery. We noted efficacy of physiotherapy treatment through different specific techniques and the need for development of new studies.

  2. Preoperative colonization in pediatric cardiac surgery and its impact on postoperative infections.

    PubMed

    Silvetti, Simona; Ranucci, Marco; Isgrò, Giuseppe; Villa, Valentina; Costa, Elena

    2017-08-01

    Patients with congenital heart defects are frequently hospitalized before surgery. This exposes them to a high risk for pathogen colonization. There are limited data on colonization prevalence in the pediatric cardiac population, and limited data concerning its potential role in the risk of developing infections after cardiac surgery. This study aimed to verify the impact of preoperative colonization on postoperative infections in a population of pediatric cardiac surgery patients coming from Italy and developing countries. This was a retrospective study conducted in all the patients aged ≤18 years who underwent pediatric open-heart surgery in the year 2015. Clinical data were retrieved from the institutional database for cardiac surgery patients. Data on swab cultures were retrieved from the laboratory database. Swab colonization was tested for association with infection and other outcomes. Among 169 children who performed the screening for pathogen colonization, 50% had at least one positive swab. Italian patients were (P=.001) less likely to be colonized with respect to foreign patients (relative risk 0.17, 95% CI 0.09-0.35). Postoperative infections in colonized patients occurred at a similar rate as in noncolonized patients (relative risk 1.24, 95% CI 0.64-2.39; P=.532). Colonized patients had a preoperative stay (P=.021) longer than noncolonized patients (mean difference 2 days, 95% CI 0.3-3.8 days). The results of our study suggest that the impact of preoperative colonization on outcome and postoperative infections may be negligible; larger series are required to clearly define this issue. © 2017 John Wiley & Sons Ltd.

  3. Efficacy of Prophylactic Dexmedetomidine in Preventing Postoperative Junctional Ectopic Tachycardia After Pediatric Cardiac Surgery.

    PubMed

    El Amrousy, Doaa Mohamed; Elshmaa, Nagat S; El-Kashlan, Mohamed; Hassan, Samir; Elsanosy, Mohamed; Hablas, Nahed; Elrifaey, Shimaa; El-Feky, Wael

    2017-03-01

    Postoperative junctional ectopic tachycardia is one of the most serious arrhythmias that occur after pediatric cardiac surgery, difficult to treat and better to be prevented. Our aim was to assess the efficacy of prophylactic dexmedetomidine in preventing junctional ectopic tachycardia after pediatric cardiac surgery. A prospective controlled study was carried out on 90 children who underwent elective cardiac surgery for congenital heart diseases. Patients were randomized into 2 groups. Group I (dexmedetomidine group): 60 patients received dexmedetomidine; Group II (Placebo group): 30 patients received the same amount of normal saline intravenously. The primary outcome was the incidence of postoperative junctional ectopic tachycardia. Secondary outcomes included bradycardia, hypotension, vasoactive inotropic score, ventilation time, pediatric cardiac care unit stay, length of hospital stay, and perioperative mortality. The incidence of junctional ectopic tachycardia was significantly reduced in the dexmedetomidine group (3.3%) compared with the placebo group (16.7%) with P<0.005. Heart rate while coming off cardiopulmonary bypass was significantly lower in the dexmedetomidine group (130.6±9) than the placebo group (144±7.1) with P<0.001. Mean ventilation time, and mean duration of intensive care unit and hospital stay (days) were significantly shorter in the dexmedetomidine group than the placebo group (P<0.001). However, there was no significant difference between the 2 groups as regards mortality, bradycardia, or hypotension (P>0.005). Prophylactic use of dexmedetomidine is associated with significantly decreased incidence of postoperative junctional ectopic tachycardia in children after congenital heart surgery without significant side effects. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

  4. Postoperative Biomarkers Predict Acute Kidney Injury and Poor Outcomes after Pediatric Cardiac Surgery

    PubMed Central

    Devarajan, Prasad; Zappitelli, Michael; Sint, Kyaw; Thiessen-Philbrook, Heather; Li, Simon; Kim, Richard W.; Koyner, Jay L.; Coca, Steven G.; Edelstein, Charles L.; Shlipak, Michael G.; Garg, Amit X.; Krawczeski, Catherine D.

    2011-01-01

    Acute kidney injury (AKI) occurs commonly after pediatric cardiac surgery and associates with poor outcomes. Biomarkers may help the prediction or early identification of AKI, potentially increasing opportunities for therapeutic interventions. Here, we conducted a prospective, multicenter cohort study involving 311 children undergoing surgery for congenital cardiac lesions to evaluate whether early postoperative measures of urine IL-18, urine neutrophil gelatinase-associated lipocalin (NGAL), or plasma NGAL could identify which patients would develop AKI and other adverse outcomes. Urine IL-18 and urine and plasma NGAL levels peaked within 6 hours after surgery. Severe AKI, defined by dialysis or doubling in serum creatinine during hospital stay, occurred in 53 participants at a median of 2 days after surgery. The first postoperative urine IL-18 and urine NGAL levels strongly associated with severe AKI. After multivariable adjustment, the highest quintiles of urine IL-18 and urine NGAL associated with 6.9- and 4.1-fold higher odds of AKI, respectively, compared with the lowest quintiles. Elevated urine IL-18 and urine NGAL levels associated with longer hospital stay, longer intensive care unit stay, and duration of mechanical ventilation. The accuracy of urine IL-18 and urine NGAL for diagnosis of severe AKI was moderate, with areas under the curve of 0.72 and 0.71, respectively. The addition of these urine biomarkers improved risk prediction over clinical models alone as measured by net reclassification improvement and integrated discrimination improvement. In conclusion, urine IL-18 and urine NGAL, but not plasma NGAL, associate with subsequent AKI and poor outcomes among children undergoing cardiac surgery. PMID:21836147

  5. Knowledge of and Attitudes Regarding Postoperative Pain among the Pediatric Cardiac Nursing Staff: An Indian Experience.

    PubMed

    Dongara, Ashish R; Shah, Shail N; Nimbalkar, Somashekhar M; Phatak, Ajay G; Nimbalkar, Archana S

    2015-06-01

    Pain following cardiac intervention in children is a common, but complex phenomenon. Identifying and reporting pain is the responsibility of the nursing staff, who are the primary caregivers and spend the most time with the patients. Inadequately managed pain in children may lead to multiple short- and long-term adverse effects. The aim of this cross-sectional study was to assess the knowledge and attitudes regarding postoperative pain in children among the nursing staff at B.M. Patel Cardiac Center, Karamsad, Anand, Gujarat, India. The study included 42 of the 45 nurses employed in the cardiac center. The nurses participating in the study were responsible for the care of the pediatric patients. A modified Knowledge and Attitudes Survey Regarding Pain and a sociodemographic questionnaire were administered after obtaining written informed consent. The study was approved by the institutional Human Research Ethics Committee. Mean (SD) experience in years of the nursing staff was 2.32 (1.69) years (range 1 month to 5 years). Of the nurses, 67% were posted in the cardiac surgical intensive care unit (ICU). The mean (SD) score for true/false questions was 11.48 (2.95; range 7,19). The average correct response rate of the true/false questions was 45.9%. Knowledge about pain was only affected by the ward in which the nurse was posted. In first (asymptomatic) and second (symptomatic) case scenarios, 78.6% and 59.5% underestimated pain, respectively. Knowledge and attitudes regarding pain and its management is poor among nurses. Targeted training sessions and repeated reinforcement sessions are essential for holistic patient care.

  6. Correlations between global clotting function tests, duration of operation, and postoperative chest tube drainage in pediatric cardiac surgery.

    PubMed

    Hayashi, Tamaki; Sakurai, Yoshihiko; Fukuda, Kazuyoshi; Yada, Koji; Ogiwara, Kenichi; Matsumoto, Tomoko; Yoshizawa, Hiroyuki; Takahashi, Yukihiro; Yoshikawa, Yoshiro; Hayata, Yoshihiro; Taniguchi, Shigeki; Shima, Midori

    2011-08-01

    Systemic coagulation disorders after cardiac surgery represent serious postoperative complications. There have been few reports, however, identifying preoperative coagulation tests that predict postoperative bleeding. The aim of the present study was to investigate the relationship between postoperative hemorrhage and coagulation parameters determined by global coagulation assays, to define potential predictive markers. Twenty-one pediatric patients were enrolled. Blood samples were collected before and 24 h after cardiac surgery. Laboratory investigations included platelet count, hematocrit, classical coagulation tests [prothrombin time, activated partial thromboplastin time, thrombin-antithrombin complex (TAT)], rotation thromboelastometry (ROTEM), and the thrombin generation test (TGT). The duration of the surgical procedure was recorded. Chest tube drainage was monitored for 24 h after operation as an index of postoperative hemorrhage. Comparisons between preoperative and postoperative results indicated that TAT increased significantly after operation, whereas ROTEM parameters did not show a hypercoagulable pattern. Preoperative endogenous thrombin potential (ETP) measured in the TGT and clot formation time (CFT) in the ROTEM correlated with chest tube drainage. The classical coagulation tests were not informative. Postoperatively, peak height and ETP in TGT, all ROTEM parameters, and duration of surgery were correlated with chest tube drainage. Duration of surgery was correlated with postoperative ROTEM parameters but not with TGT. Postoperative maximum clot firmness and AUC were correlated with platelet count decrease ratio. The preoperative CFT and ETP provide useful indices for predicting postoperative chest tube drainage volume. In addition, the duration of surgery also correlated with chest tube drainage and affected ROTEM parameters. © 2011 Blackwell Publishing Ltd.

  7. Association of blood products administration during cardiopulmonary bypass and excessive post-operative bleeding in pediatric cardiac surgery.

    PubMed

    Agarwal, Hemant S; Barrett, Sarah S; Barry, Kristen; Xu, Meng; Saville, Benjamin R; Donahue, Brian S; Harris, Zena L; Bichell, David P

    2015-03-01

    Our objectives were to study risk factors and post-operative outcomes associated with excessive post-operative bleeding in pediatric cardiac surgeries performed using cardiopulmonary bypass (CPB) support. A retrospective observational study was undertaken, and all consecutive pediatric heart surgeries over 1 year period were studied. Excessive post-operative bleeding was defined as 10 ml/kg/h of chest tube output for 1 h or 5 ml/kg/h for three consecutive hours in the first 12 h of pediatric cardiac intensive care unit (PCICU) stay. Risk factors including demographics, complexity of cardiac defect, CPB parameters, hematological studies, and post-operative morbidity and mortality were evaluated for excessive bleeding. 253 patients were studied, and 107 (42 %) met the criteria for excessive bleeding. Bayesian model averaging revealed that greater volume of blood products transfusion during CPB was significantly associated with excessive bleeding. Multiple logistic regression analysis of blood products transfusion revealed that increased volume of packed red blood cells (PRBCs) administration for CPB prime and during CPB was significantly associated with excessive bleeding (p = 0.028 and p = 0.0012, respectively). Proportional odds logistic regression revealed that excessive bleeding was associated with greater time to achieve negative fluid balance, prolonged mechanical ventilation, and duration of PCICU stay (p < 0.001) after adjusting for multiple parameters. A greater volume of blood products administration, especially PRBCs transfusion for CPB prime, and during the CPB period is associated with excessive post-operative bleeding. Excessive bleeding is associated with worse post-operative outcomes.

  8. Modified Ultrafiltration During Cardiopulmonary Bypass and Postoperative Course of Pediatric Cardiac Surgery

    PubMed Central

    Ziyaeifard, Mohsen; Alizadehasl, Azin; Massoumi, Gholamreza

    2014-01-01

    Context: The use of cardiopulmonary bypass (CPB) provokes the inflammatory responses associated with ischemic/reperfusion injury, hemodilution and other agents. Exposure of blood cells to the bypass circuit surface starts a systemic inflammatory reaction that may causes post-CPB organ dysfunction, particularly in lungs, heart and brain. Evidence Acquisition: We investigated in the MEDLINE, PUBMED, and EMBASE databases and Google scholar for every available article in peer reviewed journals between 1987 and 2013, for related subjects to CPB with conventional or modified ultrafiltration (MUF) in pediatrics cardiac surgery patients. Results: MUF following separation from extracorporeal circulation (ECC) provides well known advantages in children with improvements in the hemodynamic, pulmonary, coagulation and other organs functions. Decrease in blood transfusion, reduction of total body water, and blood loss after surgery, are additional benefits of MUF. Conclusions: Consequently, MUF has been associated with attenuation of morbidity after pediatric cardiac surgery. In this review, we tried to evaluate the current evidence about MUF on the organ performance and its effect on post-CPB morbidity in pediatric patients. PMID:25478538

  9. Catheters, wires, tubes and drains on postoperative radiographs of pediatric cardiac patients: the whys and wherefores.

    PubMed

    Teele, Sarah A; Emani, Sitaram M; Thiagarajan, Ravi R; Teele, Rita L

    2008-10-01

    Surgical treatment of congenital heart disease has advanced dramatically since the first intracardiac repairs in the mid-20th century. Previously inoperable lesions have become the focus of routine surgery and patients are managed successfully in intensive care units around the world. As a result, increasing numbers of postoperative images are processed by departments of radiology in children's hospitals. It is important that the radiologist accurately documents and describes the catheters, wires, tubes and drains that are present on the chest radiograph. This article reviews the reasons for the placement and positioning of perioperative equipment in children who have surgical repair of atrial septal defect, ventricular septal defect or transposition of the great arteries. Also included are a brief synopsis of each cardiac anomaly, the surgical procedure for its correction, and an in-depth discussion of the postoperative chest radiograph including illustrations of catheters, wires, tubes and drains.

  10. The effect of preoperative intravenous paracetamol administration on postoperative fever in pediatrics cardiac surgery.

    PubMed

    Abdollahi, Mohammad-Hasan; Foruzan-Nia, Khalil; Behjati, Mostafa; Bagheri, Babak; Khanbabayi-Gol, Mehdi; Dareshiri, Shahla; Pishgahi, Alireza; Zarezadeh, Rafie; Lotfi-Naghsh, Nazgol; Lotfi-Naghsh, Ainaz; Naghavi-Behzad, Mohammad

    2014-09-01

    Post-operative fever is a common complication of cardiac operations, which is known to be correlated with a greater degree of cognitive dysfunction 6 weeks after cardiac surgery. The aim of the present study was to examine efficacy and safety of single dose intravenous Paracetamol in treatment of post-operative fever in children undergoing cardiac surgery. In this randomised, double-blind, placebo-controlled clinical trial, 80 children, aged 1-12 years, presenting for open heart surgery were entered in the trial and randomly allocated into two groups: Placebo and Paracetamol. After induction of anaesthesia, 15 mg/kg intravenous Paracetamol solution was infused during 1 h in the Paracetamol group. Patients in placebo group received 15 mg/kg normal saline infusion during the same time. Since the end of operation until next 24 h in intensive care unit, axillary temperature of the two group patients was recorded in 4-h intervals. Any fever that occurred during this period had been treated with Paracetamol suppository (125 mg) and the amount of antipyretic drug consumption for each patient had been recorded. In order to examine the safety of Paracetamol, patients were evaluated for drug complication at the same time. Mean axillary temperature during first 24 h after operation was significantly lower in Paracetamol group compared with placebo group (P = 0.001). Overall fever incidence during 24 h after operation was higher in placebo group compared with Paracetamol group (P = 0.012). Of Paracetamol group patients, 42.5% compared with 15% of placebo group participants had no consumption of antipyretic agent (Paracetamol suppository) during 24 h after operation (P = 0.001). This study suggests that single dose administration of intravenous Paracetamol before paediatric cardiac surgeries using cardiopulmonary bypass; reduce mean body temperature in the first 24 h after operation.

  11. The effect of preoperative intravenous paracetamol administration on postoperative fever in pediatrics cardiac surgery

    PubMed Central

    Abdollahi, Mohammad-Hasan; Foruzan-nia, Khalil; Behjati, Mostafa; Bagheri, Babak; Khanbabayi-Gol, Mehdi; Dareshiri, Shahla; Pishgahi, Alireza; Zarezadeh, Rafie; Lotfi-Naghsh, Nazgol; Lotfi-Naghsh, Ainaz; Naghavi-Behzad, Mohammad

    2014-01-01

    Background: Post-operative fever is a common complication of cardiac operations, which is known to be correlated with a greater degree of cognitive dysfunction 6 weeks after cardiac surgery. The aim of the present study was to examine efficacy and safety of single dose intravenous Paracetamol in treatment of post-operative fever in children undergoing cardiac surgery. Materials and Methods: In this randomised, double-blind, placebo-controlled clinical trial, 80 children, aged 1-12 years, presenting for open heart surgery were entered in the trial and randomly allocated into two groups: Placebo and Paracetamol. After induction of anaesthesia, 15 mg/kg intravenous Paracetamol solution was infused during 1 h in the Paracetamol group. Patients in placebo group received 15 mg/kg normal saline infusion during the same time. Since the end of operation until next 24 h in intensive care unit, axillary temperature of the two group patients was recorded in 4-h intervals. Any fever that occurred during this period had been treated with Paracetamol suppository (125 mg) and the amount of antipyretic drug consumption for each patient had been recorded. In order to examine the safety of Paracetamol, patients were evaluated for drug complication at the same time. Results: Mean axillary temperature during first 24 h after operation was significantly lower in Paracetamol group compared with placebo group (P = 0.001). Overall fever incidence during 24 h after operation was higher in placebo group compared with Paracetamol group (P = 0.012). Of Paracetamol group patients, 42.5% compared with 15% of placebo group participants had no consumption of antipyretic agent (Paracetamol suppository) during 24 h after operation (P = 0.001). Conclusion: This study suggests that single dose administration of intravenous Paracetamol before paediatric cardiac surgeries using cardiopulmonary bypass; reduce mean body temperature in the first 24 h after operation. PMID:25298601

  12. The efficacy of pre-emptive dexmedetomidine versus amiodarone in preventing postoperative junctional ectopic tachycardia in pediatric cardiac surgery

    PubMed Central

    El-Shmaa, Nagat S.; El Amrousy, Doaa; El Feky, Wael

    2016-01-01

    Objective: The objective of this study was to assess the effectiveness of pre-emptive dexmedetomidine versus amiodarone in preventing junctional ectopic tachycardia (JET) in pediatric cardiac surgery. Design: This is a prospective, controlled study. Setting: This study was carried out at a single university hospital. Subjects and Methods: Ninety patients of both sexes, American Society of Anesthesiologists Physical Status II and III, age range from 2 to 18 years, and scheduled for elective cardiac surgery for congenital and acquired heart diseases were selected as the study participants. Interventions: Patients were randomized into three groups (30 each). Group I received dexmedetomidine 1 mcg/kg diluted in 100 ml of normal saline intravenously (IV) over a period of 20 min, and the infusion was completed 10 min before the induction followed by a 0.5 mcg/kg/h infusion for 72 h postoperative, Group II received amiodarone 5 mg/kg diluted in 100 ml of normal saline IV over a period of 20 min, and the infusion was completed 10 min before the induction followed by a 10–15 mcg/kg/h infusion for 72 h postoperative, and Group III received 100 ml of normal saline IV. Primary outcome was the incidence of postoperative JET. Secondary outcomes included vasoactive-inotropic score, ventilation time (VT), pediatric cardiac care unit stay, hospital length of stay, and perioperative mortality. Measurements and Main Results: The incidence of JET was significantly reduced in Group I and Group II (P = 0.004) compared to Group III. Heart rate while coming off from cardiopulmonary bypass (CPB) was significantly low in Group I compared to Group II and Group III (P = 0.000). Mean VT, mean duration of Intensive Care Unit stay, and length of hospital stay (day) were significantly short (P = 0.000) in Group I and Group II compared to Group III (P = 0.000). Conclusion: Perioperative use of dexmedetomidine and amiodarone is associated with significantly decreased incidence of JET as compared

  13. Pediatric cardiac emergencies.

    PubMed

    Lee, C; Mason, L J

    2001-06-01

    Successful management of pediatric cardiac emergencies requires an accurate diagnosis to institute an appropriate plan of therapy. The diagnosis, however, is not always straightforward, as evidenced by the nonspecific clinical picture that can be presented by congenital heart defects. Entertaining the possibility of a cardiac problem in neonates with pulmonary symptoms unresponsive to standard therapies is crucial for successful management of patients with congenital heart disease. In addition to ventilatory support, prostaglandin E1 infusions or emergency interventional cardiac catheterization is often a life-saving initial measure in patients with acutely decompensated congenital cardiac lesions that require a patent ductus arteriosus for survival. Pericardial tamponade is associated with various acquired and iatrogenic causes. Emergent pericardiocentesis is mandatory when cardiovascular compromise occurs. The goal of anesthetic management is to maintain cardiac output. With the increasing use of central venous catheters in neonatal ICUs and the high mortality rate for central venous catheter-related cardiac tamponade, the diagnosis must be considered in any patient with a central venous catheter in situ who acutely develops unexplained hypotension, bradycardia, and diminished pulses. Arrhythmias also can cause hemodynamic instability in infants and children. Supraventricular tachycardia is by far the most common emergently presenting arrhythmia in the pediatric population. Unstable patients require immediate intravenous adenosine or synchronized cardioversion. Complete heart block is rare, but it can lead to congestive heart failure and occasionally to cardiovascular collapse and sudden death. Emergency treatment of complete heart block includes pharmacologic support and temporary or permanent pacemaker placement as indicated. In infants, congestive heart failure usually is related to congenital heart disease, whereas in older children, it tends to be secondary

  14. Pathophysiology of Post-Operative Low Cardiac Output Syndrome.

    PubMed

    Epting, Conrad L; McBride, Mary E; Wald, Eric L; Costello, John M

    2016-01-01

    Low cardiac output syndrome frequently complicates the post-operative care of infants and children following cardiac surgery. The onset of low cardiac output follows a predictable course in the hours following cardiopulmonary bypass, as myocardial performance declines in the face of an elevated demand for cardiac output. When demand outstrips supply, shock ensues, and early recognition and intervention can decrease mortality. Multifactorial in etiology, this article will discuss the pathophysiology of low cardiac output syndrome, including myocardial depression following bypass, altered cardiac loading conditions, and inflammation driving a hypermetabolic state. Contributions from altered neurohormonal, thyroid, and adrenal axes will also be discussed. Sources included the clinical experiences of four cardiac intensivists, supported throughout by primary sources and relevant reviews obtained through PubMed searches and from seminal textbooks in the field. This article addresses the second of eight topics comprising the special issue entitled "Pharmacologic strategies with afterload reduction in low cardiac output syndrome after pediatric cardiac surgery".

  15. Pediatric cardiac surgery in Indonesia.

    PubMed

    Asou, T; Rachmat, J

    1998-10-01

    Pediatric cardiac surgery in Indonesia first developed thanks to the cooperation of various cardiac centers abroad. The establishment of the 'Harapan Kita' National Cardiac Center in 1985 was one of the most important initial steps. Thereafter, the discipline advanced remarkably in terms of the number of the operations performed and the variety of the diseases treated and, as a result, the surgical outcome also improved. Numerous problems remain to be solved. Only 1% of the children with congenital heart disease are today properly treated in Indonesia. Some of the underlying problems responsible for this situation include a shortage of pediatric cardiac professionals, the lack of the information and education on the part of the patients, and a shortage of funding, both privately and publicly. It would thus be welcome for pediatric cardiac surgeons, cardiologists and nurses in Indonesia to learn about congenital heart disease from doctors and nurses in advanced countries in order to improve the outlook at home.

  16. [Pediatric postoperative quality analysis : Pain and postoperative nausea and vomiting].

    PubMed

    Balga, I; Konrad, C; Meissner, W

    2013-09-01

    For the evaluation of postoperative pain therapy, nausea and vomiting (PONV), the Children's Hospital in Lucerne acts as a member of the postoperative quality improvement project QUIPSi for children. Initial results and the potential for evaluation of the postoperative pain therapy and PONV are presented here. The central questions are whether the postoperative therapy concept is sufficient and if QUIPSi serves as an ideal tool for postoperative quality improvement? Over a period of 1.5 years a total of 460 children aged between 4 to 17 years evaluated their postoperative pain, requirements for more analgesic medicine and the incidence of PONV according to a standardized questionnaire on the first postoperative day. The administration of analgesic medicine was recorded until finishing the questionnaire. In this study 5 pediatric outpatient operation groups (hernia repair n = 36, bone surgery n = 23, metal removal surgery n = 31, circumcision n = 65 and soft tissue surgery n = 49) and 9 pediatric inpatient operation groups (appendectomy n = 21, bone surgery n = 78, metal removal surgery n = 24, orchidopexy n = 31, combined operation (orchidopexy + hernia repair or circumcision) n = 14, otoplasty n = 9, tonsillectomy n = 41 and pectus excavatum surgery n = 6 and soft tissue surgery n=28) could be classified. All operation groups except the inpatient and outpatient soft tissue surgery groups received regional or infiltration anesthesia. Analgesic medicine was prescribed with the maximum permitted daily dose per kg body weight (paracetamol 100 mg/kgBW, metamizole 80 mg/kgBW, diclofenac 3 mg/kgBW and ibuprofen 40 mg/kgBW; in reserve tramadol 8 mg/kgBW and nalbuphine 2.4 mg/kgBW). The following operation groups complained of persistent pain (scale according to Hicks 0-10) and/or required more pain medicine (%): pediatric outpatients circumcision 5.1/19 %, pediatric inpatients appendectomy 6.5/43 %, tonsillectomy 6.4/32 %, pectus excavatum surgery 7.7/33 %, orchidopexy 4

  17. Effectiveness of prophylactic non-invasive ventilation on respiratory function in the postoperative phase of pediatric cardiac surgery: a randomized controlled trial

    PubMed Central

    Silva, Camilla R. S.; Andrade, Lívia B.; Maux, Danielle A. S. X.; Bezerra, Andreza L.; Duarte, Maria C. M. B.

    2016-01-01

    ABSTRACT Objective To evaluate the effectiveness of prophylactic, non-invasive ventilation (NIV) on respiratory function in seven- to 16-year-old children in the post-operative phase of cardiac surgery. Method A randomized, controlled trial with 50 children who had undergone cardiac surgery with median sternotomy. After extubation, patients were randomly assigned to one of two groups: control group (n=26), which received instructions regarding posture, early ambulation, and cough stimulation, and CPAP group (continuous positive airway pressure; n=24), which received the same instructions as the control group and CPAP=10 cmH20 twice daily for 30 minutes from the 1st to the 5th post-operative day (POD). As a primary outcome, lung function was evaluated before and on the 1st, 3rd, and 5th PODs with measures of respiratory rate (RR), tidal volume (TV), slow vital capacity (SVC), inspiratory capacity (IC), minute volume (MV), peak expiratory flow (PEF), and maximal inspiratory pressure (MIP). As secondary outcomes, the time of hospitalization and intensive care were recorded. A mixed, linear regression model and z-test were used to analyze respiratory function, considering p<0.05. Results All variables, except RR and MV, showed a significant drop on the 1st POD, with gradual recovery; however, only MIP had returned to pre-operative values on the 5th POD in both groups. The RR showed a significant increase on the 1st POD, with a gradual reduction but without returning to baseline. In the intergroup analysis, significant improvement (p=0.04) was observed only in PEF in the CPAP group on the 1st DPO. The length of hospitalization and intensive care showed no significant differences. Conclusion NIV was safe and well accepted in this group of patients, and the protocol used was effective in improving PEF on the 1st DPO in the CPAP group. PMID:27706462

  18. Sepsis in the Pediatric Cardiac Intensive Care Unit

    PubMed Central

    Wheeler, Derek S.; Jeffries, Howard E.; Zimmerman, Jerry J.; Wong, Hector R.; Carcillo, Joseph A.

    2012-01-01

    The survival rate for children with congenital heart disease (CHD) has increased significantly coincident with improved techniques in cardiothoracic surgery, cardiopulmonary bypass, and myocardial protection, and post-operative care. Cardiopulmonary bypass, likely in combination with ischemia-reperfusion injury, hypothermia, and surgical trauma, elicits a complex, systemic inflammatory response that is characterized by activation of the complement cascade, release of endotoxin, activation of leukocytes and the vascular endothelium, and release of pro-inflammatory cytokines. This complex inflammatory state causes a transient immunosuppressed state, which may increase the risk of hospital-acquired infection in these children. Postoperative sepsis occurs in nearly 3% of children undergoing cardiac surgery and significantly increases length of stay in the pediatric cardiac intensive care unit as well as the risk for mortality. Herein, we review the epidemiology, pathobiology, and management of sepsis in the pediatric cardiac intensive care unit. PMID:22337571

  19. Analgesia and sedation after pediatric cardiac surgery.

    PubMed

    Wolf, Andrew R; Jackman, Lara

    2011-05-01

    In recent years, the importance of appropriate intra-operative anesthesia and analgesia during cardiac surgery has become recognized as a factor in postoperative recovery. This includes the early perioperative management of the neonate undergoing radical surgery and more recently the care surrounding fast-track and ultra fast-track surgery. However, outside these areas, relatively little attention has focused on postoperative sedation and analgesia within the pediatric intensive care unit (PICU). This reflects perceived priorities of the primary disease process over the supporting structure of PICU, with a generic approach to sedation and analgesia that can result in additional morbidities and delayed recovery. Management of the marginal patient requires optimisation of not only cardiac and other attendant pathophysiology, but also every aspect of supportive care. Individualized sedation and analgesia strategies, starting in the operating theater and continuing through to hospital discharge, need to be regarded as an important aspect of perioperative care, to speed the process of recovery. © 2010 Blackwell Publishing Ltd.

  20. Postoperative Pain Trajectories in Cardiac Surgery Patients

    PubMed Central

    Chapman, C. Richard; Zaslansky, Ruth; Donaldson, Gary W.; Shinfeld, Amihay

    2012-01-01

    Poorly controlled postoperative pain is a longstanding and costly problem in medicine. The purposes of this study were to characterize the acute pain trajectories over the first four postoperative days in 83 cardiac surgery patients with a mixed effects model of linear growth to determine whether statistically significant individual differences exist in these pain trajectories, and to compare the quality of measurement by trajectory with conventional pain measurement practices. The data conformed to a linear model that provided slope (rate of change) as a basis for comparing patients. Slopes varied significantly across patients, indicating that the direction and rate of change in pain during the first four days of recovery from surgery differed systematically across individuals. Of the 83 patients, 24 had decreasing pain after surgery, 24 had increasing pain, and the remaining 35 had approximately constant levels of pain over the four postoperative days. PMID:22448322

  1. Cardiac catheterization in the early post-operative period after congenital cardiac surgery.

    PubMed

    Nicholson, George T; Kim, Dennis W; Vincent, Robert N; Kogon, Brian E; Miller, Bruce E; Petit, Christopher J

    2014-12-01

    This study sought to demonstrate that early cardiac catheterization, whether used solely as a diagnostic modality or for the use of transcatheter interventional techniques, can be used effectively and with an acceptable risk in the post-operative period. Cardiac catheterization offers important treatment for patients with congenital heart disease. Early post-operative cardiac catheterization is often necessary to diagnose and treat residual anatomic defects. Experience with interventional catheterization to address post-operative concerns is limited. This was a retrospective cohort study. The medical and catheterization data of pediatric patients who underwent a cardiac catheterization ≤30 days after congenital heart surgery between November 2004 and July 2013 were reviewed. Patients who underwent right heart catheterization and endomyocardial biopsy after heart transplantation were excluded. A total of 219 catheterizations (91 interventional procedures, 128 noninterventional catheterizations) were performed on 193 patients. Sixty-five interventions (71.43%) were dilations, either balloon angioplasty or stent implantation. There was no difference in survival to hospital discharge between those who underwent an interventional versus noninterventional catheterization (p = 0.93). One-year post-operative survival was comparable between those who underwent an intervention (66%) versus diagnostic (71%) catheterization (p = 0.58). There was no difference in the incidence of major or minor complications between the interventional and diagnostic catheterization cohorts (p = 0.21). Cardiac catheterization, including transcatheter interventions, can be performed safely in the immediate post-operative period after congenital heart surgery. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

  2. Acute kidney injury after pediatric cardiac surgery

    PubMed Central

    Singh, Sarvesh Pal

    2016-01-01

    Acute kidney injury is a common complication after pediatric cardiac surgery. The definition, staging, risk factors, biomarkers and management of acute kidney injury in children is detailed in the following review article. PMID:27052074

  3. Epidemiology and Outcomes of Cardiac Arrest in Pediatric Cardiac ICUs.

    PubMed

    Alten, Jeffrey A; Klugman, Darren; Raymond, Tia T; Cooper, David S; Donohue, Janet E; Zhang, Wenying; Pasquali, Sara K; Gaies, Michael G

    2017-10-01

    In-hospital cardiac arrest occurs in 2.6-6% of children with cardiac disease and is associated with significant morbidity and mortality. Much remains unknown about cardiac arrest in pediatric cardiac ICUs; therefore, we aimed to describe cardiac arrest epidemiology in a contemporary multicenter cardiac ICU cohort. Retrospective analysis within the Pediatric Cardiac Critical Care Consortium clinical registry. Cardiac ICUs within 23 North American hospitals. All cardiac medical and surgical patients admitted from August 2014 to July 2016. None. There were 15,908 cardiac ICU encounters (6,498 medical, 9,410 surgical). 3.1% had cardiac arrest; rate was 4.8 cardiac arrest per 1,000 cardiac ICU days. Medical encounters had 50% higher rate of cardiac arrest compared with surgical encounters. Observed (unadjusted) cardiac ICU cardiac arrest prevalence varied from 1% to 5.5% among the 23 centers; cardiac arrest per 1,000 cardiac ICU days varied from 1.1 to 10.4. Over half cardiac arrest occur within 48 hours of admission. On multivariable analysis, prematurity, neonatal age, any Society of Thoracic Surgeons preoperative risk factor, and Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category 4, 5 had strongest association with surgical encounter cardiac arrest. In medical encounters, independent cardiac arrest risk factors were acute heart failure, prematurity, lactic acidosis greater than 3 mmol/dL, and invasive ventilation 1 hour after admission. Median cardiopulmonary resuscitation duration was 10 minutes, return of spontaneous circulation occurred in 64.5%, extracorporeal cardiopulmonary resuscitation in 27.2%. Unadjusted survival was 53.2% in encounters with cardiac arrest versus 98.2% without. Medical encounters had lower survival after cardiac arrest (37.7%) versus surgical encounters (62.5%); Norwood patients had less than half the survival after cardiac arrest (35.6%) compared with all others. Unadjusted survival after

  4. Kidney Outcomes 5 Years After Pediatric Cardiac Surgery

    PubMed Central

    Greenberg, Jason H.; Zappitelli, Michael; Devarajan, Prasad; Thiessen-Philbrook, Heather R.; Krawczeski, Catherine; Li, Simon; Garg, Amit X.; Coca, Steve; Parikh, Chirag R.

    2017-01-01

    IMPORTANCE Acute kidney injury (AKI) after pediatric cardiac surgery is associated with high short-term morbidity and mortality; however, the long-term kidney outcomes are unclear. OBJECTIVE To assess long-term kidney outcomes after pediatric cardiac surgery and to determine if perioperative AKI is associated with worse long-term kidney outcomes. DESIGN, SETTING, AND PARTICIPANTS This prospective multicenter cohort study recruited children between ages 1 month to 18 years who underwent cardiopulmonary bypass for cardiac surgery and survived hospitalization from 3 North American pediatric centers between July 2007 and December 2009. Children were followed up with telephone calls and an in-person visit at 5 years after their surgery. EXPOSURES Acute kidney injury defined as a postoperative serum creatinine rise from preoperative baseline by 50% or 0.3 mg/dL or more during hospitalization for cardiac surgery. MAIN OUTCOMES AND MEASURES Hypertension (blood pressure ≥95th percentile for height, age, sex, or self-reported hypertension), microalbuminuria (urine albumin to creatinine ratio >30 mg/g), and chronic kidney disease (serum creatinine estimated glomerular filtration rate [eGFR] <90 mL/min/1.73 m2 or microalbuminuria). RESULTS Overall, 131 children (median [interquartile range] age, 7.7 [5.9–9.9] years) participated in the 5-year in-person follow-up visit; 68 children (52%) were male. Fifty-seven of 131 children (44%) had postoperative AKI. At follow-up, 22 children (17%) had hypertension (10 times higher than the published general pediatric population prevalence), while 9 (8%), 13 (13%), and 1 (1%) had microalbuminuria, an eGFR less than 90 mL/min/1.73 m2, and an eGFR less than 60 mL/min/1.73 m2, respectively. Twenty-one children (18%) had chronic kidney disease. Only 5 children (4%) had been seen by a nephrologist during follow-up. There was no significant difference in renal outcomes between children with and without postoperative AKI. CONCLUSIONS AND

  5. Cardiac output measurement in pediatric anesthesia.

    PubMed

    Skowno, Justin J; Broadhead, Michael

    2008-11-01

    Maintenance of cardiovascular stability is crucial to safe anesthetic practice, but measurement of cardiac output has been technically challenging, particularly in pediatric patients. Cardiovascular monitoring has therefore generally relied upon pressure-based measurements, as opposed to flow-based measurements. The measurement of cardiac output under anesthesia and in critical care has recently become easier as a result of new techniques of measurement. This article reviews the basic concepts of and rationale for cardiac output monitoring, and then describes the techniques available for monitoring in clinical practice.

  6. Late-presenting complete heart block after pediatric cardiac surgery

    PubMed Central

    Nasser, Bana Agha; Mesned, Abdu Rahman; Mohamad, Tagelden; Kabbani, Mohamad S.

    2015-01-01

    Late presenting complete heart block after pediatric cardiac surgery is a rare complication and its management is well defined once the initial diagnosis in made timely and appropriately. In this report we described a child who underwent atrioventricular septal defect repair with a normal sinus rhythm during the postoperative period, as well as during the first 2 years of follow up. She subsequently developed complete heart block with bradycardia that required insertion of a pacemaker. Here we discuss this unusual late-presenting complication, possible risk factors, and management. PMID:26778907

  7. Impact of modified ultrafiltration on morbidity after pediatric cardiac surgery.

    PubMed

    Raja, Shahzad G; Yousufuddin, Shaik; Rasool, Faisal; Nubi, Ayo; Danton, Mark; Pollock, James

    2006-08-01

    Cardiopulmonary bypass is a double-edged sword. Without it, corrective cardiac surgery would not be possible in the majority of children with congenital heart disease. However, much of the perioperative morbidity that occurs after cardiac surgery can be attributed to a large extent to pathophysiologic processes engendered by extracorporeal circulation. One of the challenges that has confronted pediatric cardiac surgeons has been to minimize the consequences of cardiopulmonary bypass. Ultrafiltration is a strategy that has been used for many years in an effort to attenuate the effects of hemodilution that occur when small children undergo surgery with cardiopulmonary bypass. Over the past several years, a modified technique of ultrafiltration, commonly known as modified ultrafiltration, has been used with increasing enthusiasm. Multiple studies have been undertaken to assess the effects of modified ultrafiltration on organ function and postoperative morbidity following repair of congenital heart defects. This review attempts to evaluate current available scientific evidence on the impact of modified ultrafiltration on organ function and morbidity after pediatric cardiac surgery.

  8. Epidemiology of Noninvasive Ventilation in Pediatric Cardiac ICUs.

    PubMed

    Romans, Ryan A; Schwartz, Steven M; Costello, John M; Chanani, Nikhil K; Prodhan, Parthak; Gazit, Avihu Z; Smith, Andrew H; Cooper, David S; Alten, Jeffrey; Mistry, Kshitij P; Zhang, Wenying; Donohue, Janet E; Gaies, Michael

    2017-10-01

    To describe the epidemiology of noninvasive ventilation therapy for patients admitted to pediatric cardiac ICUs and to assess practice variation across hospitals. Retrospective cohort study using prospectively collected clinical registry data. Pediatric Cardiac Critical Care Consortium clinical registry. Patients admitted to cardiac ICUs at PC4 hospitals. None. We analyzed all cardiac ICU encounters that included any respiratory support from October 2013 to December 2015. Noninvasive ventilation therapy included high flow nasal cannula and positive airway pressure support. We compared patient and, when relevant, perioperative characteristics of those receiving noninvasive ventilation to all others. Subgroup analysis was performed on neonates and infants undergoing major cardiovascular surgery. To examine duration of respiratory support, we created a casemix-adjustment model and calculated adjusted mean durations of total respiratory support (mechanical ventilation + noninvasive ventilation), mechanical ventilation, and noninvasive ventilation. We compared adjusted duration of support across hospitals. The cohort included 8,940 encounters from 15 hospitals: 3,950 (44%) received noninvasive ventilation and 72% were neonates and infants. Medical encounters were more likely to include noninvasive ventilation than surgical. In surgical neonates and infants, 2,032 (55%) received postoperative noninvasive ventilation. Neonates, extracardiac anomalies, single ventricle, procedure complexity, preoperative respiratory support, mechanical ventilation duration, and postoperative disease severity were associated with noninvasive ventilation therapy (p < 0.001 for all). Across hospitals, noninvasive ventilation use ranged from 32% to 65%, and adjusted mean noninvasive ventilation duration ranged from 1 to 4 days (3-d observed mean). Duration of total adjusted respiratory support was more strongly correlated with duration of mechanical ventilation compared with noninvasive

  9. The role of postoperative chest radiography in pediatric tracheotomy.

    PubMed

    Greenberg, J S; Sulek, M; de Jong, A; Friedman, E M

    2001-07-30

    A postoperative chest radiograph has traditionally been obtained after tracheotomies to evaluate for the presence of a pneumothorax and to assess tube position. Several recent studies in adults have questioned the usefulness of routine postoperative chest radiography in uncomplicated cases, but the role of post-operative chest radiography in pediatric patients has not been previously reviewed. We performed this study to examine the clinical utility of post-tracheotomy chest radiography in pediatric patients and determine if this routine practice impacts patient management enough to merit continued usage. A retrospective review was performed of 200 consecutive pediatric patients who underwent tracheotomies by the otolaryngology service in a tertiary care pediatric hospital from January 1994 to June 1999. All patients received postoperative chest radiographs. Five of 200 patients had a new postoperative radiographic finding, with three requiring interventions. Two patients required chest tube placement for pneumothorax, and one patient required tracheostomy tube change for repositioning. Fifty-one patients, including both pneumothoraces, exhibited clinical signs of pneumothorax (decreased breath sounds or oxygen saturation) in the immediate postoperative period. Chest X-ray ruled out a pneumothorax in the remaining 49 patients. The majority of these 51 patients were less than 2 years old (94%, P=0.002) or weighed less than 17 kg (89%, P=0.004). Postoperative chest X-rays yielded clinically relevant information in 168 patients that fell into one or more of four high risk categories: age less than 2, weight less than 17 kg, emergent procedures, or concomitant central line placement. Avoiding chest X-rays in the remaining 32 patients would have resulted in potential savings of $5000, which does not reflect the actuarial cost of a missed complication. Since the majority of our patients (84%) fell into a high-risk category, we feel it would be prudent to continue

  10. Telemedicine in pediatric cardiac critical care.

    PubMed

    Munoz, Ricardo A; Burbano, Nelson H; Motoa, María V; Santiago, Gabriel; Klevemann, Matthew; Casilli, Jeanne

    2012-03-01

    To describe our international telemedicine experience in pediatric cardiac critical care. This is a case series of pediatric patients teleassisted from the Cardiac Intensive Care Unit (CICU) at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, to the CICU at Hospital Valle del Lili, Cali, Valle, Colombia, between March and December 2010. An attending intensivist from the CICU in Pittsburgh reviewed cases, monitored real-time vital signs, and gave formal medical advice as requested by the attending physician in Cali. The network connection is a Cisco (San Jose, CA)-based Secure Sockets Layer virtual private network via the Internet that allows access to the web-based interface of the Dräger(®) (Lübeck, Germany) physiological monitor system. The videoconferencing equipment consists of a standard component on a custom-made mobile cart that uses an APC(®) (West Kingston, RI) uninterruptible power supply for portable power and 3Com(®) (Hewlett-Packard, Palo Alto, CA) for wireless connectivity. A post-intervention survey regarding satisfaction with the telemedicine service was conducted. Seventy-one recommendations were given regarding 53 patients. Median age and weight were 10 months and 7.1 kg, respectively. Ventricular septal defect, transposition of the great vessels, and single ventricle accounted for most cases. The most frequent recommendations were related to surgical conduct, management of arrhythmias, and performance of cardiac catheterization studies. No technical difficulties were experienced during the monitoring of the patients. Satisfaction rates were equally high for technical and medical aspects of telemedicine service. Telemedicine is a feasible option for pediatric intensivists seeking experienced assistance in the management of complex cardiac patients. Real-time remote assistance may improve the medical care of pediatric cardiac patients treated in developing countries.

  11. Dexmedetomidine in combination with midazolam after pediatric cardiac surgery.

    PubMed

    Hasegawa, Tomomi; Oshima, Yoshihiro; Maruo, Ayako; Matsuhisa, Hironori; Tanaka, Akiko; Noda, Rei; Matsushima, Shunsuke

    2015-09-01

    Although midazolam is one of the most commonly used sedatives for infants in the intensive care unit, it has well-known disadvantages including a dose-dependent potential to induce tolerance, withdrawal, and hemodynamic depression. The aim of this study was to evaluate the clinical effects of dexmedetomidine combined with midazolam in postoperative intensive care following pediatric cardiac surgery. Forty consecutive infants who underwent cardiac surgery for isolated ventricular septal defects from January 2011 to July 2013 were enrolled in this retrospective study. They were divided into two groups according to postoperative sedation regimen: dexmedetomidine sedation with midazolam (n = 20), or midazolam sedation without dexmedetomidine (control group, n = 20). Perioperative variables were compared between the two groups. There were no significant differences in patient characteristics between the two groups. During the first 24 h after intensive care unit admission, heart rate and serum lactate levels were significantly lower in the dexmedetomidine group compared to the control group (p = 0.0292 and p = 0.0027, respectively). The maximal midazolam dose was also significantly lower in the dexmedetomidine group (0.12 ± 0.09 vs. 0.20 ± 0.08 mg kg(-1) h(-1), p = 0.0059). There were no adverse effects of dexmedetomidine such as bradycardia, hypotension, agitation, or seizures. Three (15%) patients in the control group and none in the dexmedetomidine group experienced sudden cardiopulmonary decompensation. Dexmedetomidine can provide favorable sedative properties with a reduced requirement for concomitant midazolam and stable hemodynamics with tachycardia prevention, for postoperative intensive care following pediatric cardiac surgery. © The Author(s) 2015.

  12. Factors affecting postoperative blood loss in children undergoing cardiac surgery.

    PubMed

    Faraoni, David; Van der Linden, Philippe

    2014-02-11

    We hypothesized that the influence of cyanotic disease on postoperative blood loss is closely related to age in children undergoing cardiac surgery. Here, we demonstrate that the presence of a cyanotic disease is associated with increased postoperative blood loss in children aged 1 to 6 months. Children with cyanotic disease and aged<1 month who received fresh frozen plasma during cardiopulmonary bypass had less postoperative blood loss and higher maximal clot firmness on FIBTEM than cyanotic children from all other groups. Additional studies are needed to define optimal pathophysiology-based management in children undergoing cardiac surgery.

  13. Outcomes associated with postoperative delirium after cardiac surgery.

    PubMed

    Mangusan, Ralph Francis; Hooper, Vallire; Denslow, Sheri A; Travis, Lucille

    2015-03-01

    Delirium after surgery is a common condition that leads to poor outcomes. Few studies have examined the effect of postoperative delirium on outcomes after cardiac surgery. To assess the relationship between delirium after cardiac surgery and the following outcomes: length of stay after surgery, prevalence of falls, discharge to a nursing facility, discharge to home with home health services, and use of inpatient physical therapy. Electronic medical records of 656 cardiac surgery patients were reviewed retrospectively. Postoperative delirium occurred in 161 patients (24.5%). Patients with postoperative delirium had significantly longer stays (P < .001) and greater prevalence of falls (P < .001) than did patients without delirium. Patients with delirium also had a significantly greater likelihood for discharge to a nursing facility (P < .001) and need for home health services if discharged to home (P < .001) and a significantly higher need for inpatient physical therapy (P < .001). Compared with patients without postoperative delirium, patients who had this complication were more likely to have received zolpidem and benzodiazepines postoperatively and to have a history of arrhythmias, renal disease, and congestive heart failure. Patients who have delirium after cardiac surgery have poorer outcomes than do similar patients without this complication. Development and implementation of an extensive care plan to address postoperative delirium is necessary for cardiac surgery patients who are at risk for or have delirium after the surgery. ©2015 American Association of Critical-Care Nurses.

  14. Potential Pediatric Organ Donors After Cardiac Death.

    PubMed

    Pregernig, A; Karam, O

    2016-10-01

    More than 50 people die each year on the Swiss transplant waiting list. To increase their organ donors pool, some centers have developed a post-cardiac death organ donation program. Information about its impact in the pediatric population is still scarce. The aim of this work was to determine the potential impact of a program of organ donation after cardiac in a pediatric population. This was a retrospective study of all children deceased from 2005 to 2014 in a tertiary pediatric and neonatal intensive care unit. The deceased were categorized as brain dead, deceased despite maximal resuscitation, deceased after withholding of care, and deceased after withdrawal of care. Potential organ donors were identified by the absence of medical contraindication and agonal time <120 minutes. A total of 189 nonpremature children died during the 10-year period. Of the 36 (19%) brain-dead children, only 5 became organ donors. A further 67 (35%) died despite maximal resuscitation, 31 (16%) after withholding of care, and 55 (29%) after withdrawal of care. Regarding the latter category, median agonal time was 16 minutes. Eighteen children could potentially have given ≥1 organ each. Development of organ donation after cardiac death in children could generate a 4-fold increase of the donor population. Copyright © 2016 Elsevier Inc. All rights reserved.

  15. ECLS in Pediatric Cardiac Patients

    PubMed Central

    Di Nardo, Matteo; MacLaren, Graeme; Marano, Marco; Cecchetti, Corrado; Bernaschi, Paola; Amodeo, Antonio

    2016-01-01

    Extracorporeal life support (ECLS) is an important device in the management of children with severe refractory cardiac and or pulmonary failure. Actually, two forms of ECLS are available for neonates and children: extracorporeal membrane oxygenation (ECMO) and use of a ventricular assist device (VAD). Both these techniques have their own advantages and disadvantages. The intra-aortic balloon pump is another ECLS device that has been successfully used in larger children, adolescents, and adults, but has found limited applicability in smaller children. In this review, we will present the “state of art” of ECMO in neonate and children with heart failure. ECMO is commonly used in a variety of settings to provide support to critically ill patients with cardiac disease. However, a strict selection of patients and timing of intervention should be performed to avoid the increase in mortality and morbidity of these patients. Therefore, every attempt should be done to start ECLS “urgently” rather than “emergently,” before the presence of dysfunction of end organs or circulatory collapse. Even though exciting progress is being made in the development of VADs for long-term mechanical support in children, ECMO remains the mainstay of mechanical circulatory support in children with complex anatomy, particularly those needing rapid resuscitation and those with a functionally univentricular circulation. With the increase in familiarity with ECMO, new indications have been added, such as extracorporeal cardiopulmonary resuscitation (ECPR). The literature supporting ECPR is increasing in children. Reasonable survival rates have been achieved after initiation of support during active compressions of the chest following in-hospital cardiac arrest. Contraindications to ECLS have reduced in the last 5 years and many centers support patients with functionally univentricular circulations. Improved results have been recently achieved in this complex subset of patients. PMID

  16. Caudal analgesia and cardiothoracic surgery: a look at postoperative pain scores in a pediatric population.

    PubMed

    Nguyen, Khoa N; Byrd, Heather S; Tan, Jonathan M

    2016-11-01

    Caudal epidural anesthesia has been shown to reduce stress response and shorten the time to extubation in children after cardiac surgery. Combined with general anesthesia, regional anesthesia has been proven to be safe and efficacious in the pediatric population. It is not known, however, whether the use of caudal anesthesia actually reduces postoperative pain scores and decreases postoperative opioid use. We retrospectively analyzed the charts of 199 children who underwent repair for atrial septal defect (ASD), ventricular septal defect (VSD), and Tetralogy of Fallot (TOF) at a major academic children's hospital between 2010 and 2013. Eighty-six patients underwent preoperative placement of caudal anesthesia (bupivacaine 0.25% 1 ml·kg(-1) up to 20 ml + clonidine 2mcg·kg(-1) + Duramorph 40 mcg·kg(-1) up to 2.5 mg) and 113 patients did not have a caudal block. Postoperative cardiac intensive care pain scores were analyzed according to standard nurse-recorded patient-appropriate pain scales ranging from 0 to 10 (CRIES for neonates and FLACC for 2 months-7 years). There was no statistical difference between caudal and noncaudal groups with respect to postoperative pain scores or with postoperative opioid requirements. There was a statistical significance with regard to intraoperative opioid use as noncaudal patients invariably received more opioid during the procedure. Although regional anesthesia reduced intraoperative opioid usage, there was no difference in postoperative opioid usage or pain scores. © 2016 John Wiley & Sons Ltd.

  17. Postoperative Right Ventricular Failure in Cardiac Surgery.

    PubMed

    Estrada, Victor H Nieto; Franco, Daniel L Molano; Moreno, Albert A Valencia; Gambasica, Jose A Rojas; Nunez, Cristian C Cortes

    2016-12-01

    Two cases of patients that developed right ventricular failure (RVF) after cardiac valve surgery are presented with a narrative revision of the literature. RVF involves a great challenge due to the severity of this condition; it has a low incidence among non-congenital cardiac surgery patients, is more likely associated with cardiovascular and pulmonary complications related to cardiopulmonary bypass (CPB), and is a cause of acute graft failure and of a higher early mortality in cardiac transplant. The morphologic and hemodynamic characteristics of the right ventricle and some specific factors that breed pulmonary hypertension after cardiac surgery are in favor of the onset of RVF. Due to the possibility of complications after cardiac valve repair or replacement, measures as appropriate hemodynamic monitoring, to manage oxygenation, ventilation, sedation, acid base equilibrium and perfusion goals are a requirement, as well as a normal circulating volume, and the prevention of a disproportionate rise in the afterload, to preserve the free wall of the right ventricle (RV) and the septum's contribution to the right ventricular global function and geometry. If there is no response to these basic measures, the use of advanced therapy with inotropics, intravenous or inhaled pulmonary vasodilation agents is recommended; the use of mechanical ventricular assistance stands as a last resource.

  18. Postoperative Right Ventricular Failure in Cardiac Surgery

    PubMed Central

    Estrada, Victor H. Nieto; Franco, Daniel L. Molano; Moreno, Albert A. Valencia; Gambasica, Jose A. Rojas; Nunez, Cristian C. Cortes

    2016-01-01

    Two cases of patients that developed right ventricular failure (RVF) after cardiac valve surgery are presented with a narrative revision of the literature. RVF involves a great challenge due to the severity of this condition; it has a low incidence among non-congenital cardiac surgery patients, is more likely associated with cardiovascular and pulmonary complications related to cardiopulmonary bypass (CPB), and is a cause of acute graft failure and of a higher early mortality in cardiac transplant. The morphologic and hemodynamic characteristics of the right ventricle and some specific factors that breed pulmonary hypertension after cardiac surgery are in favor of the onset of RVF. Due to the possibility of complications after cardiac valve repair or replacement, measures as appropriate hemodynamic monitoring, to manage oxygenation, ventilation, sedation, acid base equilibrium and perfusion goals are a requirement, as well as a normal circulating volume, and the prevention of a disproportionate rise in the afterload, to preserve the free wall of the right ventricle (RV) and the septum’s contribution to the right ventricular global function and geometry. If there is no response to these basic measures, the use of advanced therapy with inotropics, intravenous or inhaled pulmonary vasodilation agents is recommended; the use of mechanical ventricular assistance stands as a last resource. PMID:28197291

  19. International pediatric cardiac assistance in Croatia: results of the 10 year program.

    PubMed

    Novick, William M; Anić, Darko; Ivancan, Visnja; Di Sessa, Thomas G

    2004-08-01

    In an effort to help alleviate the lack of an adequate pediatric cardiac surgical service that existed in Croatia following 1991 the International Childrens Heart Foundation (ICHF) was asked to provide the necessary surgery. Initially, this project was undertaken as a humanitarian program to provide pediatric cardiac operations. After 5 years, the Republic of Croatia financially sponsored the program. The intended purpose of the Government Sponsored Program was to provide staff education, clinical services, and the development of an organized pediatric cardiac service team in country. The surgical results of the humanitarian program and the educational and surgical results of the Government sponsored program are reported. Review of 3 separate databases maintained in country and the database of the ICHF in Memphis, Tennessee, was undertaken. Risk classification of the operations performed was performed using the Risk Adjustment in Congenital Heart Surgery method. A total of 32 trips (11 during the Humanitarian Program, and 21 during the Government Sponsored Program) were made between April 1993 and July 2003. A total of 601 primary operations (151 - Humanitarian Program, 450 - Government Sponsored Program) were preformed. Overall mortality in the cardiac surgical department for the Government Sponsored Program was 11%, non-risk adjusted. There were 4 senior surgeons, 3 surgical residents, 6 cardiac anesthesiologists, 2 pediatric intensivists, and 3 pediatric cardiologists involved in the educational program. The combination of humanitarian and government sponsored pediatric cardiac surgical missions provided 601 Croatian children with operations. Substantial progress was made in the areas of anesthesia, perfusion, and postoperative care in the cardiac surgical intensive care unit. Despite these improvements a number of issues still exist that prevent the development of an independently functioning full service pediatric cardiac program.

  20. Postoperative conversion disorder in a pediatric patient.

    PubMed

    Judge, Amy; Spielman, Fred

    2010-11-01

    According to the Diagnostic and Statistical Manual IV (DSM IV), conversion disorder is classified as a somatoform illness and defined as an alteration or loss of physical function because of the expression of an underlying psychological ailment. This condition, previously known as hysteria, hysterical neurosis, or conversion hysteria occurs rarely, with an incidence of 11-300 cases per 100,000 people (American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Psychiatric Association, 1994). Presentation after an anesthetic is exceptional. After thorough review of the literature, fewer than 20 cases have been documented, with only two instances in patients younger than 18 years of age after general anesthesia; both were mild in nature. We present a severe case of postoperative conversion disorder that developed upon emergence from anesthesia in a previously healthy 16-year-old girl following direct laryngoscopy with vocal fold injection.

  1. Cardiopulmonary Resuscitation in Pediatric and Cardiac Intensive Care Units.

    PubMed

    Sutton, Robert M; Morgan, Ryan W; Kilbaugh, Todd J; Nadkarni, Vinay M; Berg, Robert A

    2017-10-01

    Approximately 5000 to 10,000 children suffer an in-hospital cardiac arrest requiring cardiopulmonary resuscitation (CPR) each year in the United States. Importantly, 2% to 6% of all children admitted to pediatric intensive care units (ICUs) receive CPR, as do 4% to 6% of children admitted to pediatric cardiac ICUs. Survival from pediatric ICU cardiac arrest has improved substantially during the past 20 years presumably due to improved training methods, CPR quality, and post-resuscitation care. Extracorporeal life support CPR remains an important treatment option for both cardiac and noncardiac ICU patients. Copyright © 2017 Elsevier Inc. All rights reserved.

  2. [Risk factors associated with postoperative acute renal failure in pediatric patients undergoing cardiopulmonary bypass surgery].

    PubMed

    Reyes-Flandes, Elsa Nohemí; Herrera-Landero, Alejandro; Bobadilla-González, Pascual; Núñez-Enríquez, Juan Carlos

    2017-04-01

    Acute renal failure (ARF) is a complication associated with cardiac surgery with cardiopulmonary bypass (CPB) with an impact on morbidity and mortality. To identify risk factors associated with postoperative IRA according to pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease scale in children undergoing cardiac surgery with CPB. A nested case-control study was conducted. We included children under 16 years of age attended postoperative for CBP in a pediatric intensive care unit over a period of 18 months. The cases were those who developed ARF according to the classification pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease scale during their stay in the pediatric intensive care unit. Controls were those who did not develop this complication. Logistic regression analysis was performed and adjusted odds ratio (OR) and confidence intervals at 95% (95% CI) were calculated. 91 patients (31 cases and 60 controls) with a median age of 20 months and predominance of males (53.8%) were analyzed. Independent risk factors for ARF were the intraoperative lactate level > 6 mmol/l (OR = 4.91; 95% CI 1.26-19.05; p = .02) and cyanotic heart disease (OR = 3.62; 95% CI 1.11-11.63; p = .03). This study identified that pediatric patients with lactate levels >6 mmol/l during CPB and those with cyanotic congenital heart disease are a subgroup of high risk to develop ARF after heart surgery and should be closely monitored to prevent, detect and/or treat this complication timely manner.

  3. Prothrombin Complex Concentrates in Pediatric Cardiac Surgery: The Current State and the Future.

    PubMed

    Ashikhmina, Elena; Said, Sameh; Smith, Mark M; Rodriguez, Vilmarie; Oliver, William C; Nuttall, Gregory A; Dearani, Joseph A; Schaff, Hartzell V

    2017-10-01

    After decades of practice of pediatric cardiac surgery, postoperative bleeding due to the immaturity of hemostasis, hemodilution, and hypothermia remains a concern. Recently, a new approach for adult coagulopathy after bypass has emerged. Prothrombin complex concentrates (PCCs), designed to treat bleeding in hemophilia patients, are safely and efficiently used off label for hemorrhage after bypass. However, optimal dosing, indications and contraindications, and laboratory tests to assess the efficacy of PCC use in children have not yet been established. This literature review outlines the challenges of bypass-related coagulopathy, the pharmacology, and the experience in use of PCCs, with a focus on their potential in pediatric cardiac surgery. After a thorough literature search of MEDLINE, Scopus, and Ovid databases using the term "prothrombin complex concentrate AND pediatric," 23 relevant articles were selected. The data supporting successful use of PCCs in acquired coagulopathy after cardiac surgery in adults have been increasing. Although small volume, low immunogenicity, efficiency, and speed in correcting coagulopathy are attractive qualities of PCCs for pediatric practice, current evidence is only anecdotal. The main concerns are unknown dosing regimens, the inability to closely monitor the effects of PCCs in real time, and a possibility of thrombotic complications, which can be particularly devastating in young congenital cardiac patients whose lives frequently depend upon the patency of artificial shunts. Extensive, high-quality research is warranted to fill in the gaps of knowledge regarding using PCCs in pediatric cardiac practice. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  4. Postoperative atrial fibrillation in non-cardiac and cardiac surgery: an overview.

    PubMed

    Bessissow, A; Khan, J; Devereaux, P J; Alvarez-Garcia, J; Alonso-Coello, P

    2015-06-01

    Postoperative atrial fibrillation (POAF) is the most common perioperative cardiac arrhythmia. A major risk factor for POAF is advanced age, both in non-cardiac and cardiac surgery. Following non-cardiac surgery, it is important to correct reversible conditions such as electrolytes imbalances to prevent the occurrence of POAF. Management of POAF consists of rate control and therapeutic anticoagulation if POAF persists for > 48 h and CHADS2 score > 2. After cardiac surgery, POAF affects a larger amount of patients. In addition to age, valve surgery carries the greatest risk for new AF. Rate control is the mainstay therapy in these patients. Prediction, prevention, and management of POAF should be further studied.

  5. Nurse practitioners in postoperative cardiac surgery: are they effective?

    PubMed

    Goldie, Catherine L; Prodan-Bhalla, Natasha; Mackay, Martha

    2012-01-01

    High demand for acute care nurse practitioners (ACNPs) in Canadian postoperative cardiac surgery settings has outpaced methodologically rigorous research to support the role. To compare the effectiveness of ACNP-led care to hospitalist-led care in a postoperative cardiac surgery unit in a Canadian, university-affiliated, tertiary care hospital. Patients scheduled for urgent or elective coronary artery bypass and/or valvular surgery were randomly assigned to either ACNP-led (n=22) or hospitalist-led (n=81) postoperative care. Both ACNPs and hospitalists worked in collaboration with a cardiac surgeon. Outcome variables included length of hospital stay, hospital readmission rate, postoperative complications, adherence to follow-up appointments, attendance at cardiac rehabilitation and both patient and health care team satisfaction. Baseline demographic characteristics were similar between groups except more patients in the ACNP-led group had had surgery on an urgent basis (p < or = 0.01), and had undergone more complicated surgical procedures (p < or =0.01). After discharge, more patients in the hospitalist-led group had visited their family doctor within a week (p < or =0.02) and measures of satisfaction relating to teaching, answering questions, listening and pain management were higher in the ACNP-led group. Although challenges in recruitment yielded a lower than anticipated sample size, this study contributes to our knowledge of the ACNP role in postoperative cardiac surgery. Our findings provide support for the ACNP role in this setting as patients who received care from an ACNP had similar outcomes to hospitalist-led care and reported greater satisfaction in some measures of care.

  6. Effect of Prime Blood Storage Duration on Clinical Outcome After Pediatric Cardiac Surgery.

    PubMed

    Bishnoi, Arvind Kumar; Garg, Pankaj; Patel, Kartik; Solanki, Parth; Surti, Jigar; Solanki, Atul; Shah, Komal; Patel, Sanjay

    2017-03-01

    In this study, we tested the hypothesis that in pediatric patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) with blood prime, the storage duration of the packed red blood cells (PRBCs) used in prime led to differences in postoperative complications and metabolic profiles of the patients. For this prospective observational study we included 400 pediatric patients undergoing cardiac operations using CPB and requiring PRBCs prime. To study the effect of storage duration of PRBCs on postoperative morbidity, mortality, and metabolic profile, patients were divided into four groups (based on storage duration of PRBCs used in prime). Group 1: ≤7 days, group 2: 8 to 14 days, group 3: 15 to 21 days, and group 4: >21 days. On univariate analysis, patients transfused with PRBCs stored >14 days had significantly higher incidence of postoperative complications, for example, liver dysfunction, hematological complications, sepsis, and multiorgan failure. However, after regression analysis and adjusting for the other confounder's effects, no significant association was found between storage duration of PRBCs and postoperative complications and mortality. Metabolic profile of PRBCs was observed to become deranged with increasing duration of storage. This, however, improved to near physiological range early after the initiation of CPB and remained normal one hour after weaning from CPB, irrespective of the storage duration. Storage duration of PRBCs used for priming the pediatric CPB circuit neither affects the metabolic profile of the patients on CPB or early after surgery, nor it has any association with postoperative complications and mortality.

  7. An impact evaluation of a newly developed pediatric cardiac intensive care unit.

    PubMed

    Welander, Michelle Hanna; Keller, Sheila D; Northington, LaDonna

    2015-01-01

    The highly complex pediatric patients with congenital heart disease require interprofessional teamwork and collaboration to ensure high-quality outcomes with low mortality and morbidity (Congenit Heart Dis. 2013;8:3-19). The purpose of this study was to conduct an impact evaluation for a newly formed pediatric cardiac intensive care unit (PCICU) and to answer: Is there a difference between the pediatric intensive care unit and the PCICU on clinical outcome measures of pediatric cardiac postoperative patients and nursing resources? A retrospective pretest/posttest design was used with the independent variables being type of intensive care unit. The confounding variables included demographic data, clinical outcome data, registered nurse (RN) staffing data, and RN turnover data. The setting was a large, level I pediatric medical and surgical intensive care unit (ICU) located at a children's hospital within an academic medical center. The population was pediatric cardiac postoperative patients. Patients excluded were those older than 18 years or cases without a Society of Thoracic Surgeons and European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality Category score of 1 through 5. Owen's impact evaluation method and descriptive statistical measures, t test and Pearson χ test, were used for analysis. Demographic data were comparable between the pediatric intensive care unit (n = 296) and PCICU (n = 333). No statistical differences were found in several of the clinical outcome measures. Statistically significant differences were found in surgeon (P = .00) and RN nursing hours per patient day for all cardiac patients (P = .01). The PCICU time frame had a higher RN turnover rate. The majority of quality measures were not statistically different between the 2 ICUs. Even though statistical significance was not reached, the clinical impact of the PCICU's reduction in patient infections, mortality, and ICU length of stay was noted. This evaluation has

  8. Noninvasive mechanical ventilation in immediate postoperative cardiac surgery patients.

    PubMed

    Mazullo Filho, João Batista Raposo; Bonfim, Vânia Jandira Gomes; Aquim, Esperidião Elias

    2010-12-01

    Noninvasive ventilation is routine in acute respiratory failure patients; nevertheless, the literature is controversial for its use in cardiac surgery postoperative period. To evaluate the effectiveness of preventive noninvasive ventilation in the immediate postoperative period of cardiac surgery, monitoring its impact until the sixth day of hospitalization. This was a controlled study, where patients in immediate postoperative period of cardiac surgery were randomized into two groups: control (G1) and investigational (G2) which received noninvasive ventilation set on pressure support mode and positive end expiratory pressure, for 2 hours following extubation. Were evaluated ventilatory, hemodynamical and oxygenation variables both immediately after extubation and after noninvasive ventilation in G2. Thirty-two patients completed the study, 18 in G1 and 14 in G2. The mean age was 61±16.23 years for G1 and for G2 61.5 ± 9.4 years. Of the initial twenty-seven patients in G1, nine patients (33.3%) were excluded due to invasive ventilation requirements, and three patients (11.11%) had to go back to invasive mechanical ventilation. None of the 14 G2 patients was reintubated. Patients undergoing early ventilatory support showed better results in the assessments throughout the hospitalization time. Noninvasive post-cardiac surgery ventilation was proven effective, as demonstrated by increased vital capacity, decreased respiratory rate, prevention of post-extubation acute respiratory failure and reduced reintubation rates.

  9. Training general surgery residents to avoid postoperative cardiac events.

    PubMed

    McLean, Thomas R; McGoldrick, Jennifer; Fox, Sheryl; Haller, Chris C; Arevalo, Jane

    2007-11-01

    Expertise in cardiac risk assessment takes years to acquire, but unnecessary cardiology consultation delays treatment and consumes scarce resources. A retrospective review was performed of the cardiac work-up and postoperative events during 1 year on a general surgery service. Postgraduate year 1-3 general surgery residents were instructed to obtain a cardiology consult if a patient had any of the following: (1) had undergone coronary artery intervention more than 2 years in the past; (2) was taking an anti-anginal medication (nitroglycerine, Ca channel, or beta-blocker); or (3) was symptomatic or had an abnormal electrocardiogram. Whether a patient was symptomatic was to be tempered by the nature of the planned procedure. Supervised residents screened 720 unique patients for surgery. Cardiology consultation was obtained in 37. All but 1 (97%) patient referred to cardiology met at least 1 of the earlier-described criteria; with 8 (22%) meeting all 3 criteria. On average, patients referred to the cardiologists were taking 1.4 anti-anginal medications; and 1 patient sustained a fatal myocardial infarction after referral. Cardiac imaging (stress test or catheterization) was performed on 24 (65%) referred patients and was positive in 8 (33%). After minimizing cardiac risk by medication or intervention, the surgery service declined to offer the planned procedure to 11 (30%) of the referred patients and an additional 5 (15%) patients declined surgery. The overall surgical mortality was 2%. None of the patients in this series sustained a postoperative myocardial infarction or cardiac death. Postoperative supraventricular tachycardia was not influenced significantly by cardiology consultation (5% referred patients vs 1% nonreferred). Our criteria for obtaining cardiology consultation in general surgery patients appears to appropriately select patients in need of further work-up. Information obtained from a cardiac consultation frequently leads to a re-evaluation of the

  10. Strategies for blood conservation in pediatric cardiac surgery

    PubMed Central

    Singh, Sarvesh Pal

    2016-01-01

    Cardiac surgery accounts for the majority of blood transfusions in a hospital. Blood transfusion has been associated with complications and major adverse events after cardiac surgery. Compared to adults it is more difficult to avoid blood transfusion in children after cardiac surgery. This article takes into account the challenges and emphasizes on the various strategies that could be implemented, to conserve blood during pediatric cardiac surgery. PMID:27716703

  11. Predictive model for postoperative delirium in cardiac surgical patients.

    PubMed

    Afonso, Anoushka; Scurlock, Corey; Reich, David; Raikhelkar, Jayashree; Hossain, Sabera; Bodian, Carol; Krol, Marina; Flynn, Brigid

    2010-09-01

    Delirium is a common complication following cardiac surgery, and the predictors of delirium remain unclear. The authors performed a prospective observational analysis to develop a predictive model for postoperative delirium using demographic and procedural parameters. A total of 112 adult postoperative cardiac surgical patients were evaluated twice daily for delirium using the Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Model for the ICU (CAM-ICU). The incidence of delirium was 34% (n = 38). Increased age (odds ratio [OR] = 2.5; 95% confidence interval [CI] = 1.6-3.9; P < .0001, per 10 years) and increased duration of surgery (OR = 1.3; 95% CI = 1.1-1.5; P = .0002, per 30 minutes) were independently associated with postoperative delirium. Gender, BMI, diabetes mellitus, preoperative ejection fraction, surgery type, length of cardiopulmonary bypass, intraoperative blood component administration, Acute Physiology and Chronic Health Evaluation II score, Sequential Organ Failure Assessment score, and Charlson Comorbidity Index, were not independently associated with postoperative delirium.

  12. Quality measures for congenital and pediatric cardiac surgery.

    PubMed

    Jacobs, Jeffrey Phillip; Jacobs, Marshall Lewis; Austin, Erle H; Mavroudis, Constantine; Pasquali, Sara K; Lacour-Gayet, Francois G; Tchervenkov, Christo I; Walters, Hal; Bacha, Emile A; Nido, Pedro J Del; Fraser, Charles D; Gaynor, J William; Hirsch, Jennifer C; Morales, David L S; Pourmoghadam, Kamal K; Tweddell, James S; Prager, Richard L; Mayer, John E

    2012-01-01

    This article presents 21 "Quality Measures for Congenital and Pediatric Cardiac Surgery" that were developed and approved by the Society of Thoracic Surgeons (STS) and endorsed by the Congenital Heart Surgeons' Society (CHSS). These Quality Measures are organized according to Donabedian's Triad of Structure, Process, and Outcome. It is hoped that these quality measures can aid in congenital and pediatric cardiac surgical quality assessment and quality improvement initiatives.

  13. Design and rationale of safe pediatric euglycemia after cardiac surgery: a randomized controlled trial of tight glycemic control after pediatric cardiac surgery.

    PubMed

    Gaies, Michael G; Langer, Monica; Alexander, Jamin; Steil, Garry M; Ware, Janice; Wypij, David; Laussen, Peter C; Newburger, Jane W; Goldberg, Caren S; Pigula, Frank A; Shukla, Avinash C; Duggan, Christopher P; Agus, Michael S D

    2013-02-01

    To describe the design of a clinical trial testing the hypothesis that children randomized to tight glycemic control with intensive insulin therapy after cardiac surgery will have improved clinical outcomes compared to children randomized to conventional blood glucose management. Two-center, randomized controlled trial. Cardiac ICUs at two large academic pediatric centers. Children from birth to those aged 36 months recovering in the cardiac ICU after surgery with cardiopulmonary bypass. Subjects in the tight glycemic control (intervention) group receive an intravenous insulin infusion titrated to achieve normoglycemia (target blood glucose range of 80-110 mg/dL; 4.4-6.1 mmol/L). The intervention begins at admission to the cardiac ICU from the operating room and terminates when the patient is ready for discharge from the ICU. Continuous glucose monitoring is performed during insulin infusion to minimize the risks of hypoglycemia. The standard care group has no target blood glucose range. The primary outcome is the development of any nosocomial infection (bloodstream, urinary tract, and surgical site infection or nosocomial pneumonia). Secondary outcomes include mortality, measures of cardiorespiratory function and recovery, laboratory indices of nutritional balance, immunologic, endocrinologic, and neurologic function, cardiac ICU and hospital length of stay, and neurodevelopmental outcome at 1 and 3 yrs of age. A total of 980 subjects will be enrolled (490 in each treatment arm) for sufficient power to show a 50% reduction in the prevalence of the primary outcome. Pediatric cardiac surgery patients may recognize great benefit from tight glycemic control in the postoperative period, particularly with regard to reduction of nosocomial infections. The Safe Pediatric Euglycemia after Cardiac Surgery trial is designed to provide an unbiased answer to the question of whether this therapy is indeed beneficial and to define the associated risks of therapy.

  14. The surgical prebrief as part of a five-point comprehensive approach to improving pediatric cardiac surgical team communication.

    PubMed

    Hoganson, David M; Boston, Umar S; Manning, Peter B; Eghtesady, Pirooz

    2014-10-01

    Communication is essential to the safe conduct of any critical task including cardiac surgery. After inspiration by airline crew resource management training, a communication system for the care plans of pediatric cardiac patients was developed and refined over time that encompasses the entire heart center team. Five distinct communication points are used to ensure preoperative, intraoperative, and postoperative care, which is transitioned efficiently and maintained at the highest level.

  15. Pediatric cardiac surgery: a challenge and outcome analysis of the Guatemala effort.

    PubMed

    Leon-Wyss, Juan R; Veshti, Altin; Veras, Oscar; Gaitán, Guillermo A; O'Connell, Mauricio; Mack, Ricardo A; Calvimontes, Gonzalo; Garcia, Flor; Hidalgo, Amilcar; Reyes, Alfredo; Castañeda, Aldo R

    2009-01-01

    A large underserved population of children with congenital cardiac malformation (CCM) exists in many developing countries. In recent years, several strategies have been implemented to supplement this need. These strategies include transferring children to first-world countries for surgical care or the creation of local pediatric cardiovascular surgical programs. In 1997, an effort was made to create a comprehensive pediatric cardiac care program in Guatemala. The objective of this study is to examine the outcome analysis of the Guatemala effort. The goals of our new and first pediatric cardiac care program were to: 1) provide diagnosis and treatment to all children with a CCM in Guatemala; 2) train of local staff surgeons, 3) established a foundation locally and in the United States in 1997 to serve as a fundraising instrument to acquire equipment and remodeling of the pediatric cardiac unit and also to raise funds to pay the hospital for the almost exclusively poor pediatric cardiac patients. The staff now includes 3 surgeons from Guatemala, trained by the senior surgeon (A.R.C.), seven pediatric cardiologists, 3 intensivists, and 2 anesthesiologists, as well as intensive care and ward nurses, respiratory therapists, echocardiography technicians, and support personnel. The cardiovascular program expanded in 2005 to 2 cardiac operating rooms, 1 cardiac catheterization laboratory, 1 cardiac echo lab, 4 outpatients clinics a 6-bed intensive care unit and a 4-bed stepdown unit, a 20 bed general ward (2 beds/room) and a genetics laboratory. Our center has become a referral center for children from Central America. A total of 2,630 surgical procedures were performed between February 1997 and December 2007, increasing the number of operations each year. Postoperative complication occurred in 523 of 2,630 procedures (20%). A late follow-up study was conducted of all the patients operated from 1997 to 2005. Late mortality was 2.7%. Development of a sustainable pediatric

  16. Optimal normative pediatric cardiac structure dimensions for clinical use.

    PubMed

    Awori, Mark N; Finucane, Kirsten; Gentles, Thomas L

    2011-01-01

    Cardiac structure size influences surgical decision making in pediatric cardiac surgery. Lack of universally adopted normative cardiac structure dimensions may confound decision making. A review of the relevant literature contained in 2 large databases was performed with a view to determine the optimal normative cardiac structure dimensions for clinical use. The current article initially discusses technical issues related to cardiac structure measurement and measurement normalization. It then describes the literature search strategy and examines the quality of published data in subjects below 19 years of age. The optimal normative dimension data set is then recommended.

  17. Patient radiation exposure during pediatric cardiac catheterization

    SciTech Connect

    Fellows, K.E.; Leibovic, S.J.

    1983-08-01

    Exposure air product (EAP) and center field entrance exposure (free-in-air) were measured in seventeen pediatric patients undergoing cardiac catheterization. Exposures were recorded separately for biplane fluoroscopy and cine angiocardiography using flat-plate ionization chambers. In the posterior-anterior (PA) projections, median EAP was 425 Roentgen-square centimeter (R-cm/sup 2/), with a range of 90.5-3,882 R-cm/sup 2/; 29-35% of this exposure occurred during cine filming. In the lateral projection, median EAP was 276 R-cm/sup 2/ (range 117-1,173); 52-59% of this exposure was due to cine filming. Median center field entrance exposure in the PA view was 7.86 Roentgens (R) with a range 2.16-73.9 of and in the lateral projection 7.39 R (range 2.64-24.6). As much as 25% of the exposure from the entire examination was contributed by manual ''test'' exposures to set cine radiographic kVp. We recommend use of testing circuits, which determine cine radiographic factors automatically and thus should lower levels of exposure.

  18. Pediatric cardiac surgery with echocardiographic diagnosis alone.

    PubMed Central

    Sohn, Sejung; Kim, Hae Soon; Han, Jae Jin

    2002-01-01

    The diagnostic accuracy of echocardiography alone and the safety of cardiac surgery using this diagnostic approach were retrospectively assessed in 111 children operated for congenital heart defects (CHD) during a 3.5-yr period ending in October 2001. Preoperative diagnosis was compared with the intraoperative findings obtained by surgical inspection. Perioperative death was defined as death within 30 days postoperatively. Of the patients, 70% were operated on in infancy. Seventy-six percent (84 of 111) underwent surgery after echocardiographic diagnosis alone. A high percentage of patients with patent ductus arteriosus (100%), partial atrioventricular canal (100%), coarctation of the aorta (89%), ventricular septal defect (86%), atrial septal defect (85%), and total anomalous pulmonary venous connection (75%) was operated without prior catheterization. Diagnostic errors occurred in 2.4% (2 of 84) of patients with echocardiography only and in 7.4% of patients with catheterization. No error in either group was related to surgical morbidity or mortality. There were five (6.0%) perioperative deaths in the echocardiography group and two (7.4%) in the catheterization group, with no difference in the mortality between the groups. In conclusion, many patients with CHD can be accurately diagnosed by echocardiography alone, and can safely undergo surgery without catheterization, not increasing the overall risk. PMID:12172039

  19. Immunologic and Infectious Diseases in Pediatric Cardiac Critical Care: Proceedings of the 10th International Pediatric Cardiac Intensive Care Society Conference.

    PubMed

    Axelrod, David M; Alten, Jeffrey A; Berger, John T; Hall, Mark W; Thiagarajan, Ravi; Bronicki, Ronald A

    2015-10-01

    Since the inception of the Pediatric Cardiac Intensive Care Society (PCICS) in 2003, remarkable advances in the care of children with critical cardiac disease have been developed. Specialized surgical approaches, anesthesiology practices, and intensive care management have all contributed to improved outcomes. However, significant morbidity often results from immunologic or infectious disease in the perioperative period or during a medical intensive care unit admission. The immunologic or infectious illness may lead to fever, which requires the attention and resources of the cardiac intensivist. Frequently, cardiopulmonary bypass leads to an inflammatory state that may present hemodynamic challenges or complicate postoperative care. However, inflammation unchecked by a compensatory anti-inflammatory response may also contribute to the development of capillary leak and lead to a complicated intensive care unit course. Any patient admitted to the intensive care unit is at risk for a hospital acquired infection, and no patients are at greater risk than the child treated with mechanical circulatory support. In summary, the prevention, diagnosis, and management of immunologic and infectious diseases in the pediatric cardiac intensive care unit is of paramount importance for the clinician. This review from the tenth PCICS International Conference will summarize the current knowledge in this important aspect of our field.

  20. Postoperative Pulmonary Dysfunction and Mechanical Ventilation in Cardiac Surgery

    PubMed Central

    Badenes, Rafael; Lozano, Angels; Belda, F. Javier

    2015-01-01

    Postoperative pulmonary dysfunction (PPD) is a frequent and significant complication after cardiac surgery. It contributes to morbidity and mortality and increases hospitalization stay and its associated costs. Its pathogenesis is not clear but it seems to be related to the development of a systemic inflammatory response with a subsequent pulmonary inflammation. Many factors have been described to contribute to this inflammatory response, including surgical procedure with sternotomy incision, effects of general anesthesia, topical cooling, and extracorporeal circulation (ECC) and mechanical ventilation (VM). Protective ventilation strategies can reduce the incidence of atelectasis (which still remains one of the principal causes of PDD) and pulmonary infections in surgical patients. In this way, the open lung approach (OLA), a protective ventilation strategy, has demonstrated attenuating the inflammatory response and improving gas exchange parameters and postoperative pulmonary functions with a better residual functional capacity (FRC) when compared with a conventional ventilatory strategy. Additionally, maintaining low frequency ventilation during ECC was shown to decrease the incidence of PDD after cardiac surgery, preserving lung function. PMID:25705516

  1. Risk factors and outcomes of in-hospital cardiac arrest following pediatric heart operations of varying complexity.

    PubMed

    Gupta, Punkaj; Rettiganti, Mallikarjuna; Jeffries, Howard E; Scanlon, Matthew C; Ghanayem, Nancy S; Daufeldt, Jennifer; Rice, Tom B; Wetzel, Randall C

    2016-08-01

    Multi center data regarding cardiac arrest in children undergoing heart operations of varying complexity are limited. Children <18 years undergoing heart surgery (with or without cardiopulmonary bypass) in the Virtual Pediatric Systems (VPS, LLC) Database (2009-2014) were included. Multivariable mixed logistic regression models were adjusted for patient's characteristics, surgical risk category (STS-EACTS Categories 1, 2, and 3 classified as "low" complexity and Categories 4 and 5 classified as "high" complexity), and hospital characteristics. Overall, 26,909 patients (62 centers) were included. Of these, 2.7% had cardiac arrest after cardiac surgery with an associated mortality of 31%. The prevalence of cardiac arrest was lower among patients undergoing low complexity operations (low complexity vs. high complexity: 1.7% vs. 5.9%). Unadjusted outcomes after cardiac arrest were significantly better among patients undergoing low complexity operations (mortality: 21.6% vs. 39.1%, good neurological outcomes: 78.7% vs. 71.6%). In adjusted models, odds of cardiac arrest were significantly lower among patients undergoing low complexity operations (OR: 0.55, 95% CI: 0.46-0.66). Adjusted models, however, showed no difference in mortality or neurological outcomes after cardiac arrest regardless of surgical complexity. Further, our results suggest that incidence of cardiac arrest and mortality after cardiac arrest are a function of patient characteristics, surgical risk category, and hospital characteristics. Presence of around the clock in-house attending level pediatric intensivist coverage was associated with lower incidence of post-operative cardiac arrest, and presence of a dedicated cardiac ICU was associated with lower mortality after cardiac arrest. This study suggests that the patients undergoing high complexity operations are a higher risk group with increased prevalence of post-operative cardiac arrest. These data further suggest that patients undergoing high

  2. Training Pathways in Pediatric Cardiac Intensive Care: Proceedings From the 10th International Conference of the Pediatric Cardiac Intensive Care Society.

    PubMed

    Anand, Vijay; Kwiatkowski, David M; Ghanayem, Nancy S; Axelrod, David M; DiNardo, James; Klugman, Darren; Krishnamurthy, Ganga; Siehr, Stephanie; Stromberg, Daniel; Yates, Andrew R; Roth, Stephen J; Cooper, David S

    2016-01-01

    The increase in pediatric cardiac surgical procedures and establishment of the practice of pediatric cardiac intensive care has created the need for physicians with advanced and specialized knowledge and training. Current training pathways to become a pediatric cardiac intensivist have a great deal of variability and have unique strengths and weaknesses with influences from critical care, cardiology, neonatology, anesthesiology, and cardiac surgery. Such variability has created much confusion among trainees looking to pursue a career in our specialized field. This is a report with perspectives from the most common advanced fellowship training pathways taken to become a pediatric cardiac intensivist as well as various related topics including scholarship, qualifications, and credentialing.

  3. Adhesion barrier reduces postoperative adhesions after cardiac surgery.

    PubMed

    Kaneko, Yukihiro; Hirata, Yasutaka; Achiwa, Ikuya; Morishita, Hiroyuki; Soto, Hajime; Kobayahsi, Jotaro

    2012-06-01

    Reoperation in cardiac surgery is associated with increased risk due to surgical adhesions. Application of a bioresorbable material could theoretically reduce adhesions and allow later development of a free dissection plane for cardiac reoperation. Twenty-one patients in whom a bioresorbable hyaluronic acid-carboxymethylcellulose adhesion barrier had been applied in a preceding surgery underwent reoperations, while 23 patients underwent reoperations during the same period without a prior adhesion barrier. Blinded observers graded the tenacity of the adhesions from surgical video recordings of the reoperations. No excessive bleeding requiring wound reexploration, mediastinal infection, or other complication attributable to the adhesion barrier occurred. Multiple regression analysis showed that shorter duration of the preceding surgery, non-use of cardiopulmonary bypass in the preceding surgery, and use of the adhesion barrier were significantly associated with less tenacious surgical adhesions. The use of a bioresorbable material in cardiac surgery reduced postoperative adhesions, facilitated reoperation, and did not promote complications. The use of adhesion barrier is recommended in planned staged procedures and those in which future reoperation is likely.

  4. Hyperglycemia after pediatric cardiac surgery: impact of age and residual lesions.

    PubMed

    Moga, Michael-Alice; Manlhiot, Cedric; Marwali, Eva M; McCrindle, Brian W; Van Arsdell, Glen S; Schwartz, Steven M

    2011-02-01

    We evaluated the effect of patient age and significant residual cardiac lesions on the association between hyperglycemia and adverse outcomes in children after cardiac surgery. The incidence, severity, and duration of hyperglycemia in this patient population and perioperative factors predisposing to hyperglycemia were also delineated. Retrospective, observational cohort study. Eighteen-bed pediatric cardiac critical care unit. Seven hundred seventy-two children undergoing cardiac surgery with cardiopulmonary bypass during 2006 and 2007. None. Postoperative glucose levels were reviewed in all children who underwent cardiac surgery with cardiopulmonary bypass at our institution during 2006 and 2007 who met all inclusion criteria and none of the exclusion criteria (n = 772). The composite morbidity-mortality outcome included hospital death, cardiac arrest, renal/hepatic failure, lactic acidosis, extracorporeal membrane oxygenation use, or infection. Hyperglycemia occurred in 90% of patients and resolved within 72 hrs in most without exogenous insulin. Preoperative factors, including prostaglandins, mechanical ventilation, and cyanosis, were significantly associated with increased odds of significant hyperglycemia (>180 mg/dL for >12 hrs or any level >270 mg/dL) as were increased surgical complexity and perioperative steroid administration. Thirty-one percent of the entire cohort reached the composite outcome and the odds were significantly increased after 54 hrs of mild (elevated, but <180 mg/dL), 12 hrs of moderate (180-270 mg/dL), or any period of severe hyperglycemia (>270 mg/dL). Neonates (<1 month of age) tolerated longer periods of hyperglycemia before showing increased odds of reaching the composite morbidity-mortality end point. In the setting of important residual cardiac lesions, mild or moderate hyperglycemia was not as strongly associated with adverse outcomes. Age and residual cardiac lesions are important modifiers of the association between

  5. Implementation of a transfusion algorithm to reduce blood product utilization in pediatric cardiac surgery.

    PubMed

    Whitney, Gina; Daves, Suanne; Hughes, Alex; Watkins, Scott; Woods, Marcella; Kreger, Michael; Marincola, Paula; Chocron, Isaac; Donahue, Brian

    2013-07-01

    The goal of this project is to measure the impact of standardization of transfusion practice on blood product utilization and postoperative bleeding in pediatric cardiac surgery patients. Transfusion is common following cardiopulmonary bypass (CPB) in children and is associated with increased mortality, infection, and duration of mechanical ventilation. Transfusion in pediatric cardiac surgery is often based on clinical judgment rather than objective data. Although objective transfusion algorithms have demonstrated efficacy for reducing transfusion in adult cardiac surgery, such algorithms have not been applied in the pediatric setting. This quality improvement effort was designed to reduce blood product utilization in pediatric cardiac surgery using a blood product transfusion algorithm. We implemented an evidence-based transfusion protocol in January 2011 and monitored the impact of this algorithm on blood product utilization, chest tube output during the first 12 h of intensive care unit (ICU) admission, and predischarge mortality. When compared with the 12 months preceding implementation, blood utilization per case in the operating room odds ratio (OR) for the 11 months following implementation decreased by 66% for red cells (P = 0.001) and 86% for cryoprecipitate (P < 0.001). Blood utilization during the first 12 h of ICU did not increase during this time and actually decreased 56% for plasma (P = 0.006) and 41% for red cells (P = 0.031), indicating that the decrease in OR transfusion did not shift the transfusion burden to the ICU. Postoperative bleeding, as measured by chest tube output in the first 12 ICU hours, did not increase following implementation of the algorithm. Monthly surgical volume did not change significantly following implementation of the algorithm (P = 0.477). In a logistic regression model for predischarge mortality among the nontransplant patients, after accounting for surgical severity and duration of CPB, use of the transfusion

  6. Postoperative Hypoglycemia Is Associated With Worse Outcomes After Cardiac Operations.

    PubMed

    Johnston, Lily E; Kirby, Jennifer L; Downs, Emily A; LaPar, Damien J; Ghanta, Ravi K; Ailawadi, Gorav; Kozower, Benjamin D; Kron, Irving L; McCall, Anthony L; Isbell, James M

    2017-02-01

    Hypoglycemia is a known risk of intensive postoperative glucose control in patients undergoing cardiac operations. However, neither the consequences of hypoglycemia relative to hyperglycemia, nor the possible interaction effects, have been well described. We examined the effects of postoperative hypoglycemia, hyperglycemia, and their interaction on short-term morbidity and mortality. Single-institution Society of Thoracic Surgeons (STS) database patient records from 2010 to 2014 were merged with clinical data, including blood glucose values measured in the intensive care unit (ICU). Exclusion criteria included fewer than three glucose measurements and absence of an STS predicted risk of morbidity or mortality score. Primary outcomes were operative mortality and composite major morbidity (permanent stroke, renal failure, prolonged ventilation, pneumonia, or myocardial infarction). Secondary outcomes included ICU and postoperative length of stay. Hypoglycemia was defined as below 70 mg/dL, and hyperglycemia as above 180 mg/dL. Simple and multivariable regression models were used to evaluate the outcomes. A total of 2,285 patient records met the selection criteria for analysis. The mean postoperative glucose level was 140.8 ± 18.8 mg/dL. Overall, 21.4% of patients experienced a hypoglycemic episode (n = 488), and 1.05% (n = 24) had a severe hypoglycemic episode (<40 mg/dL). The unadjusted odds ratio (UOR) for operative mortality for patients with any hypoglycemic episode compared with those without was 5.47 (95% confidence interval [CI] 3.14 to 9.54), and the UOR for major morbidity was 4.66 (95% CI 3.55 to 6.11). After adjustment for predicted risk of morbidity or mortality and other significant covariates, the adjusted odds (AOR) of operative mortality were significant for patients with any hypoglycemia (AOR 4.88, 95% CI 2.67 to 8.92) and patients with both events (AOR 8.29, 95% CI 1.83 to 37.5) but not hyperglycemia alone (AOR 1.62, 95% CI 0.56 to 4.69). The

  7. Pediatric Cardiopulmonary Bypass Circuits: A Review of Studies Conducted at the Penn State Pediatric Cardiac Research Laboratories

    PubMed Central

    Miller, Akemi; Lu, Chiajung Karen; Wang, Shigang; Umstead, Todd M.; Freeman, Willard M.; Vrana, Kent; Yang, Sung; Myers, John L.; Phelps, David S.; Zahn, Jeffrey D.; Ündar, Akif

    2009-01-01

    Abstract: Cardiopulmonary bypass (CPB) circuits are frequently necessary in the repair of congenital heart defects in infants and children. Although advances in technology and operative technique have decreased the mortality associated with cardiac procedures requiring CPB, post-operative neuro-cognitive outcome and the role of the CPB circuit in post-operative morbidity remains a significant concern. There are several factors that have been suggested to play a significant role in general post-operative outcome, including intraoperative inflammatory responses caused by the interaction of blood with circuit component surfaces, selection of appropriate perfusion mode to optimize organ function during CPB, and the introduction of gaseous microemboli into the patient’s systemic circulation through circuit manipulations and modifications. These factors are the subject of continuing research at the Penn State Hershey Children’s Hospital Pediatric Cardiac Research Laboratories, and this review will focus on the results of studies aimed at identifying circuit elements that affect the delivery of gaseous microemboli to the patient during CPB procedures, the role of anti-factor D monoclonal antibody in reducing systemic inflammation during CPB, and the results of preliminary plasma proteomics studies conducted on infants undergoing CPB. PMID:19361042

  8. Physical therapy in postoperative cardiac surgery: patient's perception.

    PubMed

    Lima, Paula Monique Barbosa; Cavalcante, Hermanny Evanio Freitas; Rocha, Angelo Roncalli Miranda; Brito, Rebeca Taciana Fernandes de

    2011-01-01

    Many strategies to improve services provided by for physiotherapy are based on patients satisfaction. Listen and observe the behavior of patients in a hospital is crucial to understanding and improvement of service and the hospital. This study aimed to identify the patient's perception undergoing cardiac surgery on the physiotherapy service provided to wards of hospitals for heart surgery reference in the city of Maceió, AL, Brazil, and from that information detect what actions are perceived as priorities for which are noteworthy plans for improvements in quality of care. Cross-sectional study, conducted in quality and quantity of reference hospitals in cardiac surgery in the city of Maceio, AL, Brazil, in the period from September to November 2008. The study included 30 users of the Sistema Único de Saúde, of which 12 (40%) female and 18 (60%) males. The average age of this sample was 49.2 ± 11.9 years and most belonged to socioeconomic class D (36.7%). It was found that only 16.7% had contact with the physiotherapist before surgery. Regarding educational guidelines about postoperative period, only 2.9% patients reported having received them. However, 56.8% rated the care as good and 100% of patients reported believing that physiotherapy could improve their health status. We suggest the implementation of preoperative physical therapy protocols with preventive measures and educational as well as new researchs that may characterize the population of users of health plans/private.

  9. Association of BMI and pediatric urologic postoperative events: Results from pediatric NSQIP.

    PubMed

    Kurtz, Michael P; McNamara, Erin R; Schaeffer, Anthony J; Logvinenko, Tanya; Nelson, Caleb P

    2015-08-01

    Elevated body mass index (BMI) is a well-known risk factor for perioperative complications in adults, but has not been investigated in children undergoing urologic procedures. Given the low rate of complications associated with urologic surgery, a large sample is required for their characterization, but BMI is frequently not available in administrative databases. Here we report results from the first nationally based, prospectively assembled cohort analyzed with respect to the association of BMI with 30-day postoperative events for pediatric urologic procedures. To determine the association of elevated BMI with overall 30-day postoperative events and wound complications in a large national sample of children undergoing urologic procedures. We queried the 2012 Pediatric National Surgical Quality Improvement Program database (NSQIP), defining obesity as a BMI above the 95th percentile and overweight above the 85th percentile, per CDC definitions. We used BMI <85th percentile as a referent group. Complications were collected within 30 days of the procedure. Comorbidity was classified on a linear scale using a validated pediatric-specific comorbidity score, and procedures were classified as genital, abdominal without bowel involvement, or abdominal with bowel involvement. Univariate and multivariate logistic models were used to test significance of associations. 2871 patients aged 2-18 years were analyzed. Of these, 420 (14.6%) were overweight and 440 (15.3%) were obese. A summary of 30-day events and complications is shown in the structured abstract table. On multivariate analysis adjusting for age, gender, class of procedure, and comorbidity, BMI remained a significant risk factor for 30-day events when comparing BMI ≥85th percentile to BMI <85th percentile (OR 1.36, 95% CI 1.03-1.8, p = 0.035). An exploratory subgroup analysis examining the rate of wound complications demonstrated an odds ratio of 2.36 (95% CI 1.28-4.35, p = 0.006) for BMI >85th percentile on

  10. Epidemiology and Outcomes After In-Hospital Cardiac Arrest After Pediatric Cardiac Surgery

    PubMed Central

    Gupta, Punkaj; Jacobs, Jeffrey P.; Pasquali, Sara K.; Hill, Kevin D.; Gaynor, J. William; O’Brien, Sean M.; He, Max; Sheng, Shubin; Schexnayder, Stephen M.; Berg, Robert A.; Nadkarni, Vinay M.; Imamura, Michiaki; Jacobs, Marshall L.

    2014-01-01

    Background Multicenter data regarding cardiac arrest in children undergoing heart operations are limited. We describe epidemiology and outcomes associated with postoperative cardiac arrest in a large multiinstitutional cohort. Methods Patients younger than 18 years in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2007 through 2012) were included. Patient factors, operative characteristics, and outcomes were described for patients with and without postoperative cardiac arrest. Multivariable models were used to evaluate the association of center volume with cardiac arrest rate and mortality after cardiac arrest, adjusting for patient and procedural factors. Results Of 70,270 patients (97 centers), 1,843 (2.6%) had postoperative cardiac arrest. Younger age, lower weight, and presence of preoperative morbidities (all p < 0.0001) were associated with cardiac arrest. Arrest rate increased with procedural complexity across common benchmark operations, ranging from 0.7% (ventricular septal defect repair) to 12.7% (Norwood operation). Cardiac arrest was associated with significant mortality risk across procedures, ranging from 15.4% to 62.3% (all p < 0.0001). In multivariable analysis, arrest rate was not associated with center volume (odds ratio, 1.06; 95% confidence interval, 0.71 to 1.57 in low- versus high-volume centers). However, mortality after cardiac arrest was higher in low-volume centers (odds ratio, 2.00; 95% confidence interval, 1.52 to 2.63). This association was present for both high- and low-complexity operations. Conclusions Cardiac arrest carries a significant mortality risk across the stratum of procedural complexity. Although arrest rates are not associated with center volume, lower-volume centers have increased mortality after cardiac arrest. Further study of mechanisms to prevent cardiac arrest and to reduce mortality in those with an arrest is warranted. PMID:25443018

  11. Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Antihypertensives.

    PubMed

    Klugman, Darren; Goswami, Elizabeth S; Berger, John T

    2016-03-01

    Hypertension remains a common condition in pediatric cardiac intensive care. The physiologic effects of hypertension in this population are complex and are impacted by patient age, comorbidities, and primary cardiac disease. The objective of this study is to review current pharmacotherapies for the management of systemic hypertension in the pediatric cardiac ICU. Relevant literature to the treatment of systemic hypertension in children was included. Specific focus was given to literature studying the use of therapies in critically ill children and those with heart disease. Reference textbooks and drug packaging inserts were used for drug-specific pediatric guidelines. A search of MEDLINE, PubMed, and the Cochrane Database was performed to find literature about the management of hypertension in children. Metaanalyses and pediatric-specific studies were primarily considered and cross-referenced. Pertinent adult studies were included. Once the studies for inclusion were finalized, priority for data extraction was given to pediatric-specific studies that focused on children with heart disease and critical illness. Systemic hypertension is common, and there is significant heterogeneity in the patient population with critical heart disease. There are limited large, prospective analyses of safety and efficacy for pediatric drug antihypertensive agents. Despite patient heterogeneity, most pharmacotherapies are safe and efficacious.

  12. Postoperative respiratory failure after cardiac surgery: use of noninvasive ventilation.

    PubMed

    García-Delgado, Manuel; Navarrete, Inés; García-Palma, Maria José; Colmenero, Manuel

    2012-06-01

    To analyze the use of noninvasive ventilation (NIV) in respiratory failure after extubation in patients after cardiac surgery, the factors associated with respiratory failure, and the need for reintubation. Retrospective observational study. Intensive care unit in a university hospital. Patients (n = 63) with respiratory failure after extubation after cardiac surgery over a 3-year period. Mechanical NIV. Demographic and surgical data, respiratory history, causes of postoperative respiratory failure, durations of mechanical ventilation and spontaneous breathing, gas exchange values, and the mortality rate were recorded. Of 1,225 postsurgical patients, 63 (5.1%) underwent NIV for respiratory failure after extubation. The median time from extubation to the NIV application was 40 hours (18-96 hours). The most frequent cause of respiratory failure was lobar atelectasis (25.4%). The NIV failed in 52.4% of patients (33/63) who had a lower pH at 24 hours of treatment (7.35 v 7.42, p = 0.001) and a higher hospital mortality (51.5% v 6.7%, p = 0.001) than those in whom NIV was successful. An interval <24 hours from extubation to NIV was a predictive factor for NIV failure (odds ratio, 4.6; 95% confidence interval, 1.2-17.9), whereas obesity was associated with NIV success (odds ratio, 0.22; 95% confidence interval, 0.05-0.91). Reintubation was required in half of the NIV-treated patients and was associated with an increased hospital mortality rate. Early respiratory failure after extubation (≤24 hours) is a predictive factor for NIV failure. Copyright © 2012 Elsevier Inc. All rights reserved.

  13. Preoperative physiotherapy in prevention of pulmonary complications in pediatric cardiac surgery.

    PubMed

    Felcar, Josiane Marques; Guitti, José Carlos dos Santos; Marson, Antônio César; Cardoso, Jefferson Rosa

    2008-01-01

    To evaluate the occurrence and risk of pulmonary complications in children who underwent pre-and postoperative physiotherapeutic intervention in cardiac surgeries, as well as to compare these patients to those who underwent only postoperative physiotherapeutic intervention. A randomized controlled trial was performed with 135 patients from 6 years of age and younger with congenital heart disease who had undergone cardiac surgery. Patients were randomly assigned to the intervention group (G1) in which they underwent pre- and postoperative physiotherapy or to the control group (G2) in which they underwent only postoperative physiotherapy. Mann-Whitney and the Chi-square tests were used to compare the variables between the groups. The magnitude of the absolute risk was calculated by the number of patients needed to treat. Statistical significance was set at 5% (P<0.05). 17 patients (25%) in G1, and 29 patients (43.3%) in G2 presented pulmonary complications (P= 0.025), pneumonia was the most frequent complication, and among the 17 patients in G1, seven (10.3%) developed pneumonia, six (8.8%) developed atelectasis, and four (5.9%) presented complications due to both complications. In G2, 13 patients (19.4%) developed pneumonia, eight (11.9%) developed atelectasis, and eight (11.9%) developed pneumonia associated with atelectasis. Absolute risk reduction for the primary outcome was of 18.3% and the number of needed to treat was 5.5. Preoperative respiratory physiotherapy significantly reduced the risk of pulmonary complications in postoperative pediatric cardiac surgery.

  14. In-hospital pediatric cardiac arrest in Spain.

    PubMed

    López-Herce, Jesús; del Castillo, Jimena; Cañadas, Sonia; Rodríguez-Núñez, Antonio; Carrillo, Angel

    2014-03-01

    The objective was to analyze the characteristics and prognostic factors of in-hospital pediatric cardiac arrest in Spain. A prospective observational study was performed to examine in-hospital pediatric cardiac arrest. Two hundred children were studied, aged between 1 month and 18 years, with in-hospital cardiac arrest. Univariate and multivariate logistic regression analyses were performed to assess the influence of each factor on survival to hospital discharge. Return of spontaneous circulation was achieved in 74% of the patients and 41% survived to hospital discharge. The survival rate was significantly higher than that reported in a previous Spanish study 10 years earlier (25.9%). In the univariate analysis, the factors related to mortality were body weight higher than 10 kg; continuous infusion of vasoactive drugs prior to cardiac arrest; sepsis and neurological disorders as causes of cardiac arrest, the need for treatment with adrenaline, bicarbonate, and volume expansion, and prolonged cardiopulmonary resuscitation. In the multivariate analysis, the factors related to mortality were hematologic/oncologic diseases, continuous infusion of vasoactive drugs prior to cardiac arrest, cardiopulmonary resuscitation for more than 20 min, and treatment with bicarbonate and volume expansion. Survival after in-hospital cardiac arrest in children has significantly improved in recent years. The factors related to in-hospital mortality were hematologic/oncologic diseases, continuous infusion of vasoactive drugs prior to cardiac arrest, the duration of cardiopulmonary resuscitation, and treatment with bicarbonate and volume expansion. Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.

  15. Evaluation of Endotoxemia After Pediatric Cardiac Surgery With the Endotoxin Activity Assay: An Exploratory Prospective Cohort Study.

    PubMed

    Ricci, Zaccaria; Haiberger, Roberta; Pezzella, Chiara; Favia, Isabella; Cogo, Paola

    2016-02-01

    Children with congenital heart diseases undergoing surgery with cardiopulmonary bypass are exposed to a high risk of perioperative endotoxemia. The aim of our study was to prospectively evaluate endotoxin assay activity reference levels during the postoperative phase of infants undergoing cardiac surgery for congenital heart disease and to assess their association with perioperative variables and postoperative infections. Prospective exploratory single-center cohort study. Tertiary pediatric cardiac ICU. Infants undergoing cardiac surgery with cardiopulmonary bypass were enrolled. Exclusion criteria were preoperative suspected or confirmed infection, the need for extracorporeal membrane oxygenation or a ventricular assist device in any perioperative phase, surgery for heart transplantation, and/or urgent surgery. Serial measurements of endotoxin assay activity were performed at baseline, pediatric cardiac ICU arrival, postoperative day 1 and 2. Twenty-five patients were enrolled. Overall, 14 of 25 patients (58%) presented at least one endotoxin assay activity level greater than 0.4 during the study period (normal level is < 0.4). Endotoxin assay activity levels tended to significantly increase from baseline to postoperative day 1 and 2 and from pediatric cardiac ICU arrival to postoperative day 2 (p < 0.0001). Endotoxin assay activity greater than 0.6 predicted Gram-negative infections with a sensitivity of 0.40, a specificity of 0.95, a positive predictive value of 0.66, and a negative predictive value of 0.86. At multivariable regression, endotoxin assay activity on postoperative day 1 resulted independently associated with cardiopulmonary bypass duration, lactate, temperature peak, and vasoactive inotropic score at pediatric cardiac ICU arrival. Children with endotoxin assay activity levels greater than 0.6 (vs all the others) showed a significantly higher median (interquartile) number of ventilation days: 8 (2-39) versus 1.5 (1-3 (p = 0.02). This exploratory

  16. Cardiac Magnetic Resonance Imaging in Pediatric Turner Syndrome.

    PubMed

    Somerville, Scott; Rosolowsky, Elizabeth; Suntratonpipat, Somjate; Girgis, Rose; Goot, Benjamin H; Tham, Edythe B

    2016-08-01

    To compare the detection of cardiac lesions with the use of cardiac magnetic resonance imaging (CMR) and conventional echocardiography in children with Turner syndrome. Twenty-four girls with Turner syndrome, 8-18 years of age, were recruited through the Pediatric Endocrinology Program. Participants underwent CMR and echocardiography within a 2-year period, and discrepancies between the results of each modality were identified. Fifteen of 24 (63%) girls had a cardiac lesion identified on CMR or echocardiography. Both modalities identified the same lesion in 10 of 15 (67%); however, 6 of 15 (40%) participants had a lesion identified on CMR but not echocardiography. Participants with a missed lesion had a trend towards greater body mass index. Aortic dilation and bicuspid aortic valve were the most commonly missed lesions by echocardiography. CMR identifies significant cardiac lesions missed by echocardiography in pediatric patients with Turner syndrome, particularly along the aorta. These findings support the current guidelines that recommend screening CMR in addition to echocardiogram. Early identification of cardiac abnormalities in patients with Turner syndrome will allow for a greater understanding of the natural history in these patients and potentially identify candidates for earlier intervention. Copyright © 2016 Elsevier Inc. All rights reserved.

  17. Nasal Methicillin-Resistant S. Aureus is a Major Risk for Mediastinitis in Pediatric Cardiac Surgery

    PubMed Central

    2015-01-01

    Background: Mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA) is a serious complication after pediatric cardiac surgery. An outbreak of surgical site infections (SSIs) provided the motivation to implement SSI prevention measures in our institution. Methods: Subjects comprised 174 pediatric patients who underwent open-heart surgery after undergoing preoperative nasal culture screening. The incidence of SSIs and mediastinitis was compared between an early group, who underwent surgery before SSI measures (Group E, n = 73), and a recent group, who underwent surgery after these measures (Group R, n = 101), and factors contributing to the occurrence of mediastinitis were investigated. Results: The incidence of both SSIs and Mediastinitis has significantly decreased after SSI measures. With regard to factors that significantly affected mediastinitis, preoperative factors were “duration of preoperative hospitalization” and “preoperative MRSA colonization,” intraoperative factors were “Aristotle basic complexity score,” “operation time,” “cardiopulmonary bypass circuit volume” and “lowest rectal temperature.” And postoperative factor was “blood transfusion volume.” Patients whose preoperative nasal cultures were MRSA-positive suggested higher risk of MRSA mediastinitis. Conclusions: SSI prevention measures significantly reduced the occurrence of SSIs and mediastinitis. Preoperative MRSA colonization should be a serious risk factor for mediastinitis following pediatric cardiac surgeries. PMID:25641035

  18. Nasal methicillin-resistant S. aureus is a major risk for mediastinitis in pediatric cardiac surgery.

    PubMed

    Katayanagi, Tomoyuki

    2015-01-01

    Mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA) is a serious complication after pediatric cardiac surgery. An outbreak of surgical site infections (SSIs) provided the motivation to implement SSI prevention measures in our institution. Subjects comprised 174 pediatric patients who underwent open-heart surgery after undergoing preoperative nasal culture screening. The incidence of SSIs and mediastinitis was compared between an early group, who underwent surgery before SSI measures (Group E, n = 73), and a recent group, who underwent surgery after these measures (Group R, n = 101), and factors contributing to the occurrence of mediastinitis were investigated. The incidence of both SSIs and Mediastinitis has significantly decreased after SSI measures. With regard to factors that significantly affected mediastinitis, preoperative factors were "duration of preoperative hospitalization" and "preoperative MRSA colonization," intraoperative factors were "Aristotle basic complexity score," "operation time," "cardiopulmonary bypass circuit volume" and "lowest rectal temperature." And postoperative factor was "blood transfusion volume." Patients whose preoperative nasal cultures were MRSA-positive suggested higher risk of MRSA mediastinitis. SSI prevention measures significantly reduced the occurrence of SSIs and mediastinitis. Preoperative MRSA colonization should be a serious risk factor for mediastinitis following pediatric cardiac surgeries.

  19. Impact of Different Diagnostic Criteria on the Reported Prevalence of Junctional Ectopic Tachycardia After Pediatric Cardiac Surgery.

    PubMed

    Entenmann, Andreas; Michel, Miriam; Egender, Friedemann; Hessling, Vera; Kramer, Hans-Heiner

    2016-09-01

    Junctional ectopic tachycardia is a frequent complication after pediatric cardiac surgery. A uniform definition of postoperative junctional ectopic tachycardia has yet to be established in the literature. The objective of this study is to analyze differences in the general and age-related prevalence of postoperative junctional ectopic tachycardia according to different diagnostic definitions. Data files and electrocardiograms of 743 patients (age, 1 d to 17.6 yr) who underwent surgery for congenital heart disease during a 3-year period were reviewed. The prevalence of postoperative junctional ectopic tachycardia in this cohort was determined according to six different definitions identified in the literature and one definition introduced for analytical purposes. Agreement between the definitions was analyzed according to Cohen κ coefficients. A receiver operating characteristic analysis was performed to determine the ability of different definitions to discriminate between patients with increased postoperative morbidity and without. A university-affiliated tertiary pediatric cardiac PICU. Infants and children who underwent heart surgery. None. The prevalence of postoperative junctional ectopic tachycardia ranged from 2.0% to 8.3% according to the seven different definitions. Even among definitions for which the general prevalence was almost equal, the distribution according to age varied. Most definitions used a frequency criterion to define postoperative junctional ectopic tachycardia. Definitions based on a fixed frequency criterion did not identify cases of postoperative junctional ectopic tachycardia in patients older than 12 months. The grade of agreement was moderate or poor between definitions using a fixed or dynamic frequency criterion and those not based on a critical heart rate (κ = 0.37-0.66). In the receiver operating characteristic analysis, the definition with a fixed frequency criterion of 180 beats/min or an age-related frequency criterion

  20. Radiation Dose Estimation for Pediatric Patients Undergoing Cardiac Catheterization

    NASA Astrophysics Data System (ADS)

    Wang, Chu

    Patients undergoing cardiac catheterization are potentially at risk of radiation-induced health effects from the interventional fluoroscopic X-ray imaging used throughout the clinical procedure. The amount of radiation exposure is highly dependent on the complexity of the procedure and the level of optimization in imaging parameters applied by the clinician. For cardiac catheterization, patient radiation dosimetry, for key organs as well as whole-body effective, is challenging due to the lack of fixed imaging protocols, unlike other common X-ray based imaging modalities. Pediatric patients are at a greater risk compared to adults due to their greater cellular radio-sensitivities as well as longer remaining life-expectancy following the radiation exposure. In terms of radiation dosimetry, they are often more challenging due to greater variation in body size, which often triggers a wider range of imaging parameters in modern imaging systems with automatic dose rate modulation. The overall objective of this dissertation was to develop a comprehensive method of radiation dose estimation for pediatric patients undergoing cardiac catheterization. In this dissertation, the research is divided into two main parts: the Physics Component and the Clinical Component. A proof-of-principle study focused on two patient age groups (Newborn and Five-year-old), one popular biplane imaging system, and the clinical practice of two pediatric cardiologists at one large academic medical center. The Physics Component includes experiments relevant to the physical measurement of patient organ dose using high-sensitivity MOSFET dosimeters placed in anthropomorphic pediatric phantoms. First, the three-dimensional angular dependence of MOSFET detectors in scatter medium under fluoroscopic irradiation was characterized. A custom-made spherical scatter phantom was used to measure response variations in three-dimensional angular orientations. The results were to be used as angular dependence

  1. Ultrafiltration of the priming blood before cardiopulmonary bypass attenuates inflammatory response and improves postoperative clinical course in pediatric patients.

    PubMed

    Shimpo, H; Shimamoto, A; Sawamura, Y; Fujinaga, K; Kanemitsu, S; Onoda, K; Takao, M; Mitani, Y; Yada, I

    2001-01-01

    The priming solution using in cardiopulmonary bypass (CPB) for infants undergoing cardiac surgery includes considerable amounts of stored blood. Our objective was to test the hypothesis that ultrafiltration (UF) of the stored blood before CPB reduces the unfavorable effects of stored blood and the production of inflammatory cytokines. Fifty pediatric patients with congenital heart defects took part in this study. The patients were randomly divided into two groups: the UF (27 pediatric patients who received UF) and control (23 pediatric patients who did not receive UF) groups. UF was performed with a polysulphone ultrafiltrator before CPB. Blood samples were collected immediately before, during, and 1 h after CPB. The levels of cytokines (TNF-alpha, IL-1beta, IL-8), NH3, and bradykinin were determined. The serum concentrations of NH3 and bradykinin decreased significantly after UF. Compared with the control group, the UF group had significantly lower cytokine production. Water balance in UF group was better than that of control group. The UF group received significantly less inotropic support and shorter duration of ventilator support and ICU stay. We conclude that removal of bradykinin and a decrease in the levels of NH3, potassium, and pH play a significant role in reducing water retention and postoperative lung injury. UF of the blood used to prime the circuit for CPB is a safe and efficient method for use in open heart surgery in small pediatric patients.

  2. Assessment of pain during rest and during activities in the postoperative period of cardiac surgery

    PubMed Central

    de Mello, Larissa Coelho; Rosatti, Silvio Fernando Castro; Hortense, Priscilla

    2014-01-01

    Objective to assess the intensity and site of pain after Cardiac Surgery through sternotomy during rest and while performing five activities. Method descriptive study with a prospective cohort design. A total of 48 individuals participated in the study. A Multidimensional Scale for Pain Assessment was used. Results postoperative pain from cardiac surgery was moderate during rest and decreased over time. Pain was also moderate during activities performed on the 1st and 2nd postoperative days and decreased from the 3rd postoperative day, with the exception of coughing, which diminished only on the 6th postoperative day. Coughing, turning over, deep breathing and rest are presented in decreased order of intensity. The region of the sternum was the most frequently reported site of pain. Conclusion the assessment of pain in the individuals who underwent cardiac surgery during rest and during activities is extremely important to adapt management and avoid postoperative complications and delayed surgical recovery. PMID:24553714

  3. Assessment of pain during rest and during activities in the postoperative period of cardiac surgery.

    PubMed

    Mello, Larissa Coelho de; Rosatti, Silvio Fernando Castro; Hortense, Priscilla

    2014-01-01

    to assess the intensity and site of pain after Cardiac Surgery through sternotomy during rest and while performing five activities. descriptive study with a prospective cohort design. A total of 48 individuals participated in the study. A Multidimensional Scale for Pain Assessment was used. postoperative pain from cardiac surgery was moderate during rest and decreased over time. Pain was also moderate during activities performed on the 1st and 2nd postoperative days and decreased from the 3rd postoperative day, with the exception of coughing, which diminished only on the 6th postoperative day. Coughing, turning over, deep breathing and rest are presented in decreased order of intensity. The region of the sternum was the most frequently reported site of pain. the assessment of pain in the individuals who underwent cardiac surgery during rest and during activities is extremely important to adapt management and avoid postoperative complications and delayed surgical recovery.

  4. Hepatotoxicity After Continuous Amiodarone Infusion in a Postoperative Cardiac Infant

    PubMed Central

    Kicker, Jennifer S.; Haizlip, Julie A.; Buck, Marcia L.

    2012-01-01

    A former 34-week-old female infant with Down syndrome underwent surgical correction of a congenital heart defect at 5 months of age. Her postoperative course was complicated by severe pulmonary hypertension and junctional ectopic tachycardia. Following treatment with amiodarone infusion, she developed laboratory indices of acute liver injury. At their peak, liver transaminase levels were 19 to 35 times greater than the upper limit of normal. Transaminitis was accompanied by coagulopathy, hyperammonemia, and high serum lactate and lipid levels. Hepatic laboratory abnormalities began to resolve within 48 hr of stopping amiodarone infusion. Heart rate control was achieved concurrently with discovery of laboratory test result abnormalities, and no further antiarrhythmic therapy was required. The intravenous formulation of amiodarone contains the diluent polysorbate 80, which may have hepatotoxic effects. Specifically, animal studies suggest that polysorbate 80 may destabilize cell membranes and predispose to fatty change within liver architecture. Polysorbate was implicated in infant fatalities from E-ferol use in the 1980s. This case illustrates a possible adverse event by the Naranjo probability scale. Given the extent of clinically apparent hepatic injury, this patient was not rechallenged with amiodarone during the remainder of her hospitalization. With amiodarone now used as first-line pharmacologic therapy for critical tachyarrhythmia in this population, the number of children exposed to this drug should be expected to increase. Laboratory indices of liver function should be evaluated at initiation of amiodarone therapy, as well as frequently throughout duration of therapy. Consideration should be given to polysorbate-free formulation of intravenous amiodarone for use in the cohort with congenital cardiac disease. PMID:23118673

  5. Early detection of acute kidney injury after pediatric cardiac surgery

    PubMed Central

    Jefferies, John Lynn; Devarajan, Prasad

    2016-01-01

    Acute kidney injury (AKI) is increasingly recognized as a common problem in children undergoing cardiac surgery, with well documented increases in morbidity and mortality in both the short and the long term. Traditional approaches to the identification of AKI such as changes in serum creatinine have revealed a large incidence in this population with significant negative impact on clinical outcomes. However, the traditional diagnostic approaches to AKI diagnosis have inherent limitations that may lead to under-diagnosis of this pathologic process. There is a dearth of randomized controlled trials for the prevention and treatment of AKI associated with cardiac surgery, at least in part due to the paucity of early predictive biomarkers. Novel non-invasive biomarkers have ushered in a new era that allows for earlier detection of AKI. With these new diagnostic tools, a more consistent approach can be employed across centers that may facilitate a more accurate representation of the actual prevalence of AKI and more importantly, clinical investigation that may minimize the occurrence of AKI following pediatric cardiac surgery. A thoughtful management approach is necessary to mitigate the effects of AKI after cardiac surgery, which is best accomplished in close collaboration with pediatric nephrologists. Long-term surveillance for improvement in kidney function and potential development of chronic kidney disease should also be a part of the comprehensive management strategy. PMID:27429538

  6. Moore's law, Dabbawalas, and pediatric cardiac care in Sri Lanka.

    PubMed

    Samarasinghe, Duminda

    2015-01-01

    Sri Lanka is an island nation in Indian Ocean that provides free healthcare to all citizens through government healthcare system. It has commendable health indices in the region. Pediatric cardiac services have rapidly progressed over past few years helping to further bring down infant and under-five mortality rates. Lady Ridgeway Hospital for Children (LRH) is the only tertiary care referral center for children with heart disease in the country. Currently it performs approximately 1,000 cardiac catheterizations and 1,000 cardiac surgeries every year. Target is to double the surgical output to treat all children with heart diseases in a timely and appropriate manner. Being a middle-income country, this is not an easy task. Technology used in diagnosis and treatment of congenital heart diseases is rapidly advancing with its price tag. In such a setting, it is challenging to proceed to achieve this target in a resource-limited environment.

  7. Moore's law, Dabbawalas, and pediatric cardiac care in Sri Lanka

    PubMed Central

    Samarasinghe, Duminda

    2015-01-01

    Sri Lanka is an island nation in Indian Ocean that provides free healthcare to all citizens through government healthcare system. It has commendable health indices in the region. Pediatric cardiac services have rapidly progressed over past few years helping to further bring down infant and under-five mortality rates. Lady Ridgeway Hospital for Children (LRH) is the only tertiary care referral center for children with heart disease in the country. Currently it performs approximately 1,000 cardiac catheterizations and 1,000 cardiac surgeries every year. Target is to double the surgical output to treat all children with heart diseases in a timely and appropriate manner. Being a middle-income country, this is not an easy task. Technology used in diagnosis and treatment of congenital heart diseases is rapidly advancing with its price tag. In such a setting, it is challenging to proceed to achieve this target in a resource-limited environment. PMID:26085764

  8. Cardiac Dysfunction in a Porcine Model of Pediatric Malnutrition

    PubMed Central

    Fabiansen, Christian; Lykke, Mikkel; Hother, Anne-Louise; Koch, Jørgen; Nielsen, Ole Bækgaard; Hunter, Ingrid; Goetze, Jens P.; Friis, Henrik; Thymann, Thomas

    2015-01-01

    Background Half a million children die annually of severe acute malnutrition and cardiac dysfunction may contribute to the mortality. However, cardiac function remains poorly examined in cases of severe acute malnutrition. Objective To determine malnutrition-induced echocardiographic disturbances and longitudinal changes in plasma pro-atrial natriuretic peptide and cardiac troponin-T in a pediatric porcine model. Methods and Results Five-week old piglets (Duroc-x-Danish Landrace-x-Yorkshire) were fed a nutritionally inadequate maize-flour diet to induce malnutrition (MAIZE, n = 12) or a reference diet (AGE-REF, n = 12) for 7 weeks. Outcomes were compared to a weight-matched reference group (WEIGHT-REF, n = 8). Pro-atrial natriuretic peptide and cardiac troponin-T were measured weekly. Plasma pro-atrial natriuretic peptide decreased in both MAIZE and AGE-REF during the first 3 weeks but increased markedly in MAIZE relative to AGE-REF during week 5–7 (p≤0.001). There was overall no difference in plasma cardiac troponin-T between groups. However, further analysis revealed that release of cardiac troponin-T in plasma was more frequent in AGE-REF compared with MAIZE (OR: 4.8; 95%CI: 1.2–19.7; p = 0.03). However, when release occurred, cardiac troponin-T concentration was 6.9-fold higher (95%CI: 3.0–15.9; p<0.001) in MAIZE compared to AGE-REF. At week 7, the mean body weight in MAIZE was lower than AGE-REF (8.3 vs 32.4 kg, p<0.001), whereas heart-weight relative to body-weight was similar across the three groups. The myocardial performance index was 86% higher in MAIZE vs AGE-REF (p<0.001) and 27% higher in MAIZE vs WEIGHT-REF (p = 0.025). Conclusions Malnutrition associates with cardiac dysfunction in a pediatric porcine model by increased myocardial performance index and pro-atrial natriuretic peptide and it associates with cardiac injury by elevated cardiac troponin-T. Clinical studies are needed to see if the same applies for children suffering from

  9. [Neurological disorders after cardiac surgery: Diagnosis of cerebral tumors in the postoperative period].

    PubMed

    López Álvarez, A; Rodríguez Fernández, P; Román Fernández, A; Filgueira Dávila, E; Gálvez Gómez, D; González Monzón, V

    2014-11-01

    The incidence of neurologic disorders in the postoperative period of cardiac surgery is high and usually due to a combination of pre- and intraoperative factors. We present 2 patients with brain tumors diagnosed in the immediate postoperative period after sudden onset of neurologic dysfunction. Image studies yielded clinically useful information in these 2 cases.

  10. Patient doses from fluoroscopically guided cardiac procedures in pediatrics

    NASA Astrophysics Data System (ADS)

    Martinez, L. C.; Vano, E.; Gutierrez, F.; Rodriguez, C.; Gilarranz, R.; Manzanas, M. J.

    2007-08-01

    Infants and children are a higher risk population for radiation cancer induction compared to adults. Although some values on pediatric patient doses for cardiac procedures have been reported, data to determine reference levels are scarce, especially when compared to those available for adults in diagnostic and therapeutic procedures. The aim of this study is to make a new contribution to the scarce published data in pediatric cardiac procedures and help in the determination of future dose reference levels. This paper presents a set of patient dose values, in terms of air kerma area product (KAP) and entrance surface air kerma (ESAK), measured in a pediatric cardiac catheterization laboratory equipped with a biplane x-ray system with dynamic flat panel detectors. Cardiologists were properly trained in radiation protection. The study includes 137 patients aged between 10 days and 16 years who underwent diagnostic catheterizations or therapeutic procedures. Demographic data and technical details of the procedures were also gathered. The x-ray system was submitted to a quality control programme, including the calibration of the transmission ionization chamber. The age distribution of the patients was 47 for <1 year; 52 for 1-<5 years; 25 for 5-<10 years and 13 for 10-<16 years. Median values of KAP were 1.9, 2.9, 4.5 and 15.4 Gy cm2 respectively for the four age bands. These KAP values increase by a factor of 8 when moving through the four age bands. The probability of a fatal cancer per fluoroscopically guided cardiac procedure is about 0.07%. Median values of ESAK for the four age bands were 46, 50, 56 and 163 mGy, which lie far below the threshold for deterministic effects on the skin. These dose values are lower than those published in previous papers.

  11. Patient doses from fluoroscopically guided cardiac procedures in pediatrics.

    PubMed

    Martinez, L C; Vano, E; Gutierrez, F; Rodriguez, C; Gilarranz, R; Manzanas, M J

    2007-08-21

    Infants and children are a higher risk population for radiation cancer induction compared to adults. Although some values on pediatric patient doses for cardiac procedures have been reported, data to determine reference levels are scarce, especially when compared to those available for adults in diagnostic and therapeutic procedures. The aim of this study is to make a new contribution to the scarce published data in pediatric cardiac procedures and help in the determination of future dose reference levels. This paper presents a set of patient dose values, in terms of air kerma area product (KAP) and entrance surface air kerma (ESAK), measured in a pediatric cardiac catheterization laboratory equipped with a biplane x-ray system with dynamic flat panel detectors. Cardiologists were properly trained in radiation protection. The study includes 137 patients aged between 10 days and 16 years who underwent diagnostic catheterizations or therapeutic procedures. Demographic data and technical details of the procedures were also gathered. The x-ray system was submitted to a quality control programme, including the calibration of the transmission ionization chamber. The age distribution of the patients was 47 for <1 year; 52 for 1-<5 years; 25 for 5-<10 years and 13 for 10-<16 years. Median values of KAP were 1.9, 2.9, 4.5 and 15.4 Gy cm(2) respectively for the four age bands. These KAP values increase by a factor of 8 when moving through the four age bands. The probability of a fatal cancer per fluoroscopically guided cardiac procedure is about 0.07%. Median values of ESAK for the four age bands were 46, 50, 56 and 163 mGy, which lie far below the threshold for deterministic effects on the skin. These dose values are lower than those published in previous papers.

  12. Care of pediatric tracheostomy in the immediate postoperative period and timing of first tube change.

    PubMed

    Lippert, Dylan; Hoffman, Matthew R; Dang, Phat; McMurray, J Scott; Heatley, Diane; Kille, Tony

    2014-12-01

    To analyze the safety of a standardized pediatric tracheostomy care protocol in the immediate postoperative period and its impact on tracheostomy related complications. Retrospective case series. Pediatric patients undergoing tracheotomy from February 2010-February 2014. In 2012, a standardized protocol was established regarding postoperative pediatric tracheostomy care. This protocol included securing newly placed tracheostomy tubes using a foam strap with hook and loop fastener rather than twill ties, placing a fresh drain sponge around the tracheostomy tube daily, and performing the first tracheostomy tube change on postoperative day 3 or 4. Outcome measures included rate of skin breakdown and presence of a mature stoma allowing for a safe first tracheostomy tube change. Two types of tracheotomy were performed based on patient age: standard pediatric tracheotomy and adult-style tracheotomy with a Bjork flap. Patients were analyzed separately based on age and the type of tracheotomy performed. Thirty-seven patients in the pre-protocol group and 35 in the post-protocol group were analyzed. The rate of skin breakdown was significantly lower in the post-protocol group (standard: p=0.0048; Bjork flap: p=0.0003). In the post-protocol group, all tube changes were safely accomplished on postoperative day three or four, and the stomas were deemed to be adequately matured to do so in all cases. A standardized postoperative pediatric tracheostomy care protocol resulted in decreased rates of skin breakdown and demonstrated that pediatric tracheostomy tubes can be safely changed as early as 3 days postoperatively. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  13. Return of Viable Cardiac Function After Sonographic Cardiac Standstill in Pediatric Cardiac Arrest.

    PubMed

    Steffen, Katherine; Thompson, W Reid; Pustavoitau, Aliaksei; Su, Erik

    2017-01-01

    Sonographic cardiac standstill during adult cardiac arrest is associated with failure to get return to spontaneous circulation. This report documents 3 children whose cardiac function returned after standstill with extracorporeal membranous oxygenation. Sonographic cardiac standstill may not predict cardiac death in children.

  14. [Acute kidney injury after pediatric cardiac surgery: risk factors and outcomes. Proposal for a predictive model].

    PubMed

    Cardoso, Bárbara; Laranjo, Sérgio; Gomes, Inês; Freitas, Isabel; Trigo, Conceição; Fragata, Isabel; Fragata, José; Pinto, Fátima

    2016-02-01

    To characterize the epidemiology and risk factors for acute kidney injury (AKI) after pediatric cardiac surgery in our center, to determine its association with poor short-term outcomes, and to develop a logistic regression model that will predict the risk of AKI for the study population. This single-center, retrospective study included consecutive pediatric patients with congenital heart disease who underwent cardiac surgery between January 2010 and December 2012. Exclusion criteria were a history of renal disease, dialysis or renal transplantation. Of the 325 patients included, median age three years (1 day-18 years), AKI occurred in 40 (12.3%) on the first postoperative day. Overall mortality was 13 (4%), nine of whom were in the AKI group. AKI was significantly associated with length of intensive care unit stay, length of mechanical ventilation and in-hospital death (p<0.01). Patients' age and postoperative serum creatinine, blood urea nitrogen and lactate levels were included in the logistic regression model as predictor variables. The model accurately predicted AKI in this population, with a maximum combined sensitivity of 82.1% and specificity of 75.4%. AKI is common and is associated with poor short-term outcomes in this setting. Younger age and higher postoperative serum creatinine, blood urea nitrogen and lactate levels were powerful predictors of renal injury in this population. The proposed model could be a useful tool for risk stratification of these patients. Copyright © 2015 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

  15. Harmonic scalpel reduces bleeding and postoperative complications in redo cardiac surgery.

    PubMed

    Luciani, Nicola; Anselmi, Amedeo; Gaudino, Mario; Nasso, Giuseppe; Glieca, Franco; Martinelli, Lorenzo; Santarelli, Filippo; Perisano, Mario; Possati, Gianfederico

    2005-09-01

    Intraoperative and postoperative bleeding and injuries to cardiac structures are among the main determinants of complications and hospital and intensive care unit stay after cardiac reinterventions. The harmonic scalpel has been reported to achieve optimal tissue dissection with little blood loss. The present retrospective work was performed to evaluate the safety and usefulness of this device in redo cardiac surgery. Ninety-six redo cardiac surgery patients were operated on with the use of harmonic scalpel, and 105 redo patients operated on by traditional electrocautery and scissors were selected from our database and served as controls. Intraoperative and postoperative data of the two groups were collected and compared. Univariate and multiple logistic regression analyses were performed for identification of factors associated with death and with major and minor complications in the overall study population and in both groups, separately. Although mortality and major postoperative morbidity were comparable in the two groups, harmonic scalpel patients presented markedly reduced postoperative bleeding, lower incidence of minor complications, cardiac injuries, major arrhythmias, and need for transfusions. Operative time and mean intensive care unit stay were shorter. Use of ultrascissor was found to be a protective factor against minor morbidity at multivariate analysis. Our data suggest that harmonic scalpel is safe and is associated with better in-hospital outcome and lower postoperative blood loss in redo cardiac surgery.

  16. Impact of preoperative defecation pattern on postoperative constipation for patients undergoing cardiac surgery.

    PubMed

    Iyigun, Emine; Ayhan, Hatice; Demircapar, Aslı; Tastan, Sevinc

    2017-02-01

    To analyse the impact of preoperative defecation pattern on postoperative defecation pattern for patients undergoing cardiac surgery. Constipation is a neglected problem that occurs frequently after cardiac surgery. Descriptive study. The study sample comprised 102 patients who underwent cardiac surgery. A Descriptive Information Form, Rome III Diagnostic Criteria, Constipation Severity Instrument, Postoperative Defecation Pattern Evaluation Form and Bristol Stool Form Scale were used for data collection and analysis. The Constipation Severity Instrument scores of just over one-third (37·2%) of the patients who were constipated prior to surgery were higher compared to those who were not constipated. Following cardiac surgery, 39·2% of patients developed constipation and 80% of these patients were constipated prior to cardiac surgery. The findings indicate a significantly high relationship between preoperative and postoperative defecation pattern (r = 0·71, p < 0·001). Preoperative defecation pattern is a determining factor for the development of postoperative constipation for patients undergoing cardiac surgery. During the preoperative period, clinical nurses may evaluate the patients' defecation patterns using valid and reliable scales and follow the defecation of the patients, especially patients with defecation problems, during the postoperative period. © 2016 John Wiley & Sons Ltd.

  17. Validation of the Pediatric Cardiac Quality of Life Inventory

    PubMed Central

    Marino, Bradley S.; Tomlinson, Ryan S.; Wernovsky, Gil; Drotar, Dennis; Newburger, Jane W.; Mahony, Lynn; Mussatto, Kathleen; Tong, Elizabeth; Cohen, Mitchell; Andersen, Charlotte; Shera, David; Khoury, Philip R.; Wray, Jo; Gaynor, J. William; Helfaer, Mark A.; Kazak, Anne E.; Shea, Judy A.

    2012-01-01

    OBJECTIVE The purpose of this multicenter study was to confirm the validity and reliability of the Pediatric Cardiac Quality of Life Inventory (PCQLI). METHODS Seven centers recruited pediatric patients (8–18 years of age) with heart disease (HD) and their parents to complete the PCQLI and generic health-related quality of life (Pediatric Quality of Life Inventory [PedsQL]) and non–quality of life (Self-Perception Profile for Children [SPPC]/Self-Perception Profile for Adolescents [SPPA] and Youth Self-Report [YSR]/Child Behavior Checklist [CBCL]) tools. PCQLI construct validity was assessed through correlations of PCQLI scores between patients and parents and with severity of congenital HD, medical care utilization, and PedsQL, SPPC/SPPA, and YSR/CBCL scores. PCQLI test-retest reliability was evaluated. RESULTS The study enrolled 1605 patient-parent pairs. Construct validity was substantiated by the association of lower PCQLI scores with Fontan palliation and increased numbers of cardiac operations, hospital admissions, and physician visits (P < .001); moderate to good correlations between patient and parent PCQLI scores (r = 0.41–0.61; P <.001); and fair to good correlations between PCQLI total scores and PedsQL total (r = 0.70–0.76), SPPC/SPPA global self-worth (r = 0.43–0.46), YSR/CBCL total competency (r = 0.28–0.37), and syndrome and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-oriented scale (r = −0.58 to −0.30; P < .001) scores. Test-retest reliability correlations were excellent (r = 0.78–0.90; P < .001). CONCLUSIONS PCQLI scores are valid and reliable for children and adolescents with congenital and acquired HD and may be useful for future research and clinical management. Pediatrics 2010;126:498–508 PMID:20805147

  18. Establishment of Pediatric Cardiac Intensive Care Advanced Practice Provider Services.

    PubMed

    Gilliland, Jill; Donnellan, Amy; Justice, Lindsey; Moake, Lindy; Mauney, Jennifer; Steadman, Page; Drajpuch, David; Tucker, Dawn; Storey, Jean; Roth, Stephen J; Koch, Josh; Checchia, Paul; Cooper, David S; Staveski, Sandra L

    2016-01-01

    The addition of advanced practice providers (APPs; nurse practitioners and physician assistants) to a pediatric cardiac intensive care unit (PCICU) team is a health care innovation that addresses medical provider shortages while allowing PCICUs to deliver high-quality, cost-effective patient care. APPs, through their consistent clinical presence, effective communication, and facilitation of interdisciplinary collaboration, provide a sustainable solution for the highly specialized needs of PCICU patients. In addition, APPs provide leadership, patient and staff education, facilitate implementation of evidence-based practice and quality improvement initiatives, and the performance of clinical research in the PCICU. This article reviews mechanisms for developing, implementing, and sustaining advance practice services in PCICUs.

  19. Postoperative complications of pediatric dental general anesthesia procedure provided in Jeddah hospitals, Saudi Arabia

    PubMed Central

    Farsi, Najat; Ba'akdah, Rania; Boker, Abdulaziz; Almushayt, Abdullah

    2009-01-01

    Background Review of post-operative morbidity reports for pediatric dental care under general anesthesia (GA) show great variations. Until now, no morbidity data has been available to estimate the safety of pediatric patients under GA for dental rehabilitation in Saudi Arabia. The purposes of this study were to (1) investigate post-operative complications associated with dental care under GA and (2) correlate morbidity reports with patient's characteristics, dental procedures, and hospital protocol. Methods Study sample included 90 children attending GA for dental treatment at major governmental hospitals in Jeddah. Data were collected from every patient on three occasions, intra-operatively at the operating room, and post-operatively via phone calls in the first and third days after operation. Results Results showed that 99% of the children had one or more complaints in the first day in contrast to only 33% in the third day. Inability to eat (86%), sleepiness (71%), and pain (48%) were the most common complaints in the first day, followed by bleeding (40%), drowsiness (39%), sore throat (34%), vomiting (26%), psychological changes (24%), fever (21%), cough (12%), and nausea (8%). A great significant complaints reduction was reported by the third post-operative day. Age, gender, admission type of the patients and GA duration were the factors that showed a significant relationship with post-operative complaints. Conclusion Post-operative morbidity was common, but mostly of mild severity and limited to the first day. Hospital staff efforts should be directed to control commonly reported postoperative complaints. PMID:19228406

  20. Blood Versus Crystalloid Cardioplegia in Pediatric Cardiac Surgery: A Systematic Review and Meta-analysis.

    PubMed

    Mylonas, Konstantinos S; Tzani, Aspasia; Metaxas, Panagiotis; Schizas, Dimitrios; Boikou, Vasileios; Economopoulos, Konstantinos P

    2017-09-25

    The benefit of blood cardioplegia (BCP) compared to crystalloid cardioplegia (CCP) is still debatable. Our aim was to systematically review and synthesize all available evidence on the use of BCP and CCP to assess if any modality provides superior outcomes in pediatric cardiac surgery. A systematic literature search of the PubMed and Cochrane databases was performed with respect to the PRISMA statement (end-of-search date: January 30th, 2017). We extracted data on study design, demographics, cardioplegia regimens, and perioperative outcomes as well as relevant biochemical markers, namely cardiac troponin I (cTnI), lactate, and ATP levels at baseline, after reperfusion and postoperatively at 1, 4, 12, and 24 h as applicable. Data were appropriately pooled using random and mixed effects models. Our systematic review includes 56 studies reporting on a total of 7711 pediatric patients. A meta-analysis of the 10 eligible studies directly comparing BCP (n = 416) to CCP (n = 281) was also performed. There was no significant difference between the two groups with regard to cTnI and Lac at any measured time point, ATP levels after reperfusion, length of intensive care unit stay (WMD: -0.08, 95% CI -1.52 to 1.36), length of hospital stay (WMD: 0.13, 95% CI -0.85 to 1.12), and 30-day mortality (OR 1.11, 95% CI 0.43-2.88). Only cTnI levels at 4 h postoperatively were significantly lower with BCP (WMD: -1.62, 95% CI -2.07 to -1.18). Based on the available data, neither cardioplegia modality seems to be superior in terms of clinical outcomes, ischemia severity, and overall functional recovery.

  1. [Analysis of regional anesthetic efficacy in pediatric postop pain].

    PubMed

    Martínez-Tellería, A; Cano Serrano, M E; Martínez-Tellería, M J; Castejón Casado, J

    1997-01-01

    A randomized, double blind study was carried out in 76 paediatric surgical patients scheduled for herniography or circumcision. Patients were randomly assigned to receive ilioinguinal and iliohipogastric nerve block (group A), penile block (group B), caudal block (group C) or metamizol intravenously (group D). Postoperative pain was evaluated by Objective pain scale at the end of surgical process and at 15, 30, 60 minutes and 6 hours after surgery. Pain free time was also recorded. There was no difference between groups regarding demographic data. We find a significatively less pain scores in the children who received regional anaesthesia. In those groups the administration of any analgesic were not necessary. No side effects were recorded. We conclude that locorregional anaesthesia techniques are safe and effective for minor surgery in children, because they are easy to carry out, comfortable for the patient, and provide a good postoperative analgesia.

  2. Reduced transfusion requirement with use of fresh whole blood in pediatric cardiac surgical procedures.

    PubMed

    Jobes, David R; Sesok-Pizzini, Deborah; Friedman, David

    2015-05-01

    Pediatric patients undergoing cardiac operations are at high risk for blood loss and transfusion. A practice intended to reduce transfusion using a standard order of 2 units fresh whole blood (< 48 hours from donation) for elective cardiac operations in patients younger than 2 years of age was in place from 1995 to 2010. The objective of this study was to describe blood use in this population and to compare the results with those in published reports describing the use of blood components exclusively for transfusion. Retrospective data from a surgical registry and blood bank records for 15 consecutive years were analyzed. Transfusion requirements were identified as donor exposures for the day of operation and the next postoperative day. Transfusions were fresh whole blood, packed red blood cells, platelets, and cryoprecipitate. Donor exposures for subgroups according to procedure and age were compared with those in published reports. The cohort consisted of 4,111 patients with a median age of 94 days and a median weight of 4.4 kg. The median donor exposure was 2 (range, 0 to 28). Younger patients having complex procedures had the most donor exposures. Fewer donor exposures were incurred in all subgroups compared with reports of component use in the literature. The use of fresh whole blood for cardiac operations in children younger than 2 years old reduces donor exposures compared with published reports of component use. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  3. Using Data to Improve Quality: the Pediatric Cardiac Care Consortium.

    PubMed

    Moller, James H

    2016-01-01

    A program to collect and analyze cardiac catheterization, electrophysiologic studies and cardiac operations in children was initiated in 1982. The purpose was to help centers compare their experience and outcomes with a group of centers to determine areas where their performance might improve. Cardiac centers became members of the Pediatric Cardiac Care Consortium and submitted demographic data and copies of procedure reports regularly to a central office. Data were extracted from the reports, coded by trained coders and entered into a computer database. Annually, the data were analyzed to compare the experience of an individual center with that of the entire group of centers. The annual data were adjusted for severity on the basis of eight factors selected after discussion with participants in the Consortium. Adjustment was by multivariate analysis. Reports were prepared for each center and distributed at an annual meeting. The data were used by centers to review operations where the mortality rate exceeded +2 standard deviations of the group. With discussion, the center staff often initiated changes to improve outcome. The outcome could then be monitored by the annual reports. Our data were also utilized in the creation of the Risk Adjustment for Surgery for Congenital Heart Disease (RACHS)-1 categories of disease severity. The mortality rates of our centers were comparable with the combined hospital discharge data from New York, Massachusetts, and California. From 1982 through 2007, the mortality rates of our centers dropped for each RACHS-1 category, falling to less than 1% for categories 1 and 2 for the last 5-year period. During the 25 years, we received data from 52 centers about 137 654 patients who underwent 117 756 cardiac operations.

  4. Use of inhaled nitric oxide in pediatric cardiac intensive care unit.

    PubMed

    Öztürk, Erkut; Haydin, Sertaç; Tanıdır, İbrahim Cansaran; Özyılmaz, İsa; Ergül, Yakup; Erek, Ersin; Güzeltaş, Alper; Ödemiş, Ender; Bakır, İhsan

    2016-04-01

    Experience with administration of inhaled nitric oxide (iNO) in pediatric cardiac intensive care unit was retrospectively reviewed. Data from 32 pediatric patients treated with iNO between 2011 and 2012 were collected. Patients were divided into 3 groups: Group I comprised postoperative patients, Group II comprised newborns with persistent pulmonary hypertension (PPH), and Group III comprised patients with primary pulmonary hypertension (PH) or Eisenmenger's syndrome. Age, sex, weight, primary diagnosis, arterial blood sample, pulmonary artery pressure (PAP), systemic arterial pressure (SAP), and oxygen saturation levels were analyzed. Groups I, II, and III included 25, 3, and 4 patients, respectively. Median weight was 8 kg (range: 3-40 kg), and median age was 7 months (range: 2 days-10 years). On average, iNO treatment was initiated at the 12th hour after admission to the unit (range: 1-48 hours) and continued for a median duration of 24 hours (range: 12-168 hours). Systolic PAP was 40±15 mmHg, mean SAP was 57±18 mmHg, PAP/SAP ratio was 0.69, and oxygen saturation levels were 88% prior to iNO treatment. Following iNO treatment, PAP decreased to 24±9 mmHg (p<0.05), PAP/SAP ratio decreased to 0.4 (p<0.05), SAP showed no change (60±12 mmHg), and saturation levels increased to 98% (p<0.05). Seven patients died during follow-up (Group I, n=5; Group II, n=1; Group III, n=1). iNO seems to effectively reduce PAP, and can be used effectively and safely to prevent pulmonary hypertensive crises in pediatric cardiac intensive care units.

  5. Carotid Stenosis in Cardiac Surgery-No Difference in Postoperative Outcomes.

    PubMed

    Schultheis, Molly; Saadat, Siavash; Dombrovskiy, Victor; Frenchu, Kiersten; Kanduri, Jaya; Romero, Joseph; Lemaire, Anthony; Ghaly, Aziz; Bastides, George; Rahimi, Saum; Lee, Leonard

    2016-02-23

    Background Debate over revascularization of asymptomatic carotid stenosis before cardiac surgery is ongoing. In this study, we analyze cardiac surgery outcomes in patients with asymptomatic carotid stenosis at a single hospital. Methods In this study, 1,781 patients underwent cardiac surgery from January 2012 to June 2013; 1,357 with preoperative screening carotid duplex were included. Patient demographics, comorbidities, degree of stenosis, postoperative complications, and mortality were evaluated. Chi-square test and logistic regression analysis were performed. Results Asymptomatic stenosis was found in 403/1,357 patients (29.7%; 355 moderate and 48 severe). Patients with stenosis, compared with those without, were older (71.7 ± 11 vs. 66.3 ± 12 years; p < 0.01). Females were more likely to have stenosis (odd ratio, = 1.7; 95% confidence interval, 1.4-2.2); however, patients were predominantly male in both groups. There were no significant differences in the rates of mortality and postoperative complications, including stroke and transient ischemic attack (TIA). Postoperative TIA occurred in 3/1,357(0.2%); only one had moderate stenosis. Inhospital stroke occurred in 21/1,357 (1.5%) patients; stroke rates were 2.3% (8/355) with moderate stenosis and 2.1% (1/48) severe stenosis. There were 59/1,357 (4.3%) deaths; patients with stenosis had a mortality rate of 4.2% (17/403); however, no postoperative stroke lead to death. Multivariable logistic regression analysis with adjustment for age, gender, race, comorbidities, and postoperative complications did not show an impact of carotid stenosis on postoperative mortality and development of stroke after cardiac surgery. Conclusion This study suggests that patients with asymptomatic carotid stenosis undergoing cardiac surgery are not at increased risk of postoperative complications and mortality; thus, prophylactic carotid revascularization may not be indicated.

  6. Postoperative hypoxia and length of intensive care unit stay after cardiac surgery: the underweight paradox?

    PubMed

    Ranucci, Marco; Ballotta, Andrea; La Rovere, Maria Teresa; Castelvecchio, Serenella

    2014-01-01

    Cardiac operations with cardiopulmonary bypass can be associated with postoperative lung dysfunction. The present study investigates the incidence of postoperative hypoxia after cardiac surgery, its relationship with the length of intensive care unit stay, and the role of body mass index in determining postoperative hypoxia and intensive care unit length of stay. Single-center, retrospective study. University Hospital. Patients. Adult patients (N = 5,023) who underwent cardiac surgery with CPB. None. According to the body mass index, patients were attributed to six classes, and obesity was defined as a body mass index >30. POH was defined as a PaO2/FiO2 ratio <200 at the arrival in the intensive care unit. Postoperative hypoxia was detected in 1,536 patients (30.6%). Obesity was an independent risk factor for postoperative hypoxia (odds ratio 2.4, 95% confidence interval 2.05-2.78, P = 0.001) and postoperative hypoxia was a determinant of intensive care unit length of stay. There is a significant inverse correlation between body mass index and PaO2/FiO2 ratio, with the risk of postoperative hypoxia increasing by 1.7 folds per each incremental body mass index class. The relationship between body mass index and intensive care unit length of stay is U-shaped, with longer intensive care unit stay in underweight patients and moderate-morbid obese patients. Obese patients are at higher risk for postoperative hypoxia, but this leads to a prolonged intensive care unit stay only for moderate-morbid obese patients. Obese patients are partially protected against the deleterious effects of hemodilution and transfusions. Underweight patients present the "paradox" of a better lung gas exchange but a longer intensive care unit stay. This is probably due to a higher severity of their cardiac disease.

  7. Moderate-degree acidosis is an independent determinant of postoperative bleeding in cardiac surgery.

    PubMed

    Ranucci, M; Baryshnikova, E; Simeone, F; Ranucci, M; Scolletta, S

    2015-08-01

    Acidosis is a well-known factor leading to coagulopathy. It has been widely explored as a risk factor for severe bleeding in trauma patients. However, no information with respect to acidosis as a determinant of postoperative bleeding in cardiac surgery patients exists. The aim of this study was to investigate the role of acidosis and hyperlactatemia (HL) in determining postoperative bleeding and need for surgical revision in cardiac surgery patients. We carried out a retrospective analysis on 4521 patients receiving cardiac operations in two institutions. For each patient the preoperative data and operative profile was available. Arterial blood gas analysis data at the arrival in the intensive care unit were analyzed to investigate the association between acidosis (pH<7.35), HL (>4.0 mMol/L) and postoperative bleeding and surgical revision rate. After correction for the potential confounders, both acidosis (P=0.001) and HL (P=0.001) were significantly associated with the amount of postoperative bleeding. HL was an independent risk factor for postoperative bleeding even in absence of acidosis. Overall, surgical revision rate was 5.6% in patients with HL and no acidosis; 7.7% in patients with acidosis and HL, and 7.2% in patients with acidosis and no HL. All these values are significantly (P=0.001) higher than the ones in patients without acidosis/HL (2%). Even a moderate degree of postoperative acidosis is associated with a greater postoperative bleeding and surgical revision rate in cardiac surgery patients. Correction of acidosis with bicarbonate does not lead to an improvement of the postoperative bleeding asset.

  8. Pediatric defibrillation after cardiac arrest: initial response and outcome

    PubMed Central

    Rodríguez-Núñez, Antonio; López-Herce, Jesús; García, Cristina; Domínguez, Pedro; Carrillo, Angel; Bellón, Jose María

    2006-01-01

    Introduction Shockable rhythms are rare in pediatric cardiac arrest and the results of defibrillation are uncertain. The objective of this study was to analyze the results of cardiopulmonary resuscitation that included defibrillation in children. Methods Forty-four out of 241 children (18.2%) who were resuscitated from inhospital or out-of-hospital cardiac arrest had been treated with manual defibrillation. Data were recorded according to the Utstein style. Outcome variables were a sustained return of spontaneous circulation (ROSC) and one-year survival. Characteristics of patients and of resuscitation were evaluated. Results Cardiac disease was the major cause of arrest in this group. Ventricular fibrillation (VF) or pulseless ventricular tachycardia (PVT) was the first documented electrocardiogram rhythm in 19 patients (43.2%). A shockable rhythm developed during resuscitation in 25 patients (56.8%). The first shock (dose, 2 J/kg) terminated VF or PVT in eight patients (18.1%). Seventeen children (38.6%) needed more than three shocks to solve VF or PVT. ROSC was achieved in 28 cases (63.6%) and it was sustained in 19 patients (43.2%). Only three patients (6.8%), however, survived at 1-year follow-up. Children with VF or PVT as the first documented rhythm had better ROSC, better initial survival and better final survival than children with subsequent VF or PVT. Children who survived were older than the finally dead patients. No significant differences in response rate were observed when first and second shocks were compared. The survival rate was higher in patients treated with a second shock dose of 2 J/kg than in those who received higher doses. Outcome was not related to the cause or the location of arrest. The survival rate was inversely related to the duration of cardiopulmonary resuscitation. Conclusion Defibrillation is necessary in 18% of children who suffer cardiac arrest. Termination of VF or PVT after the first defibrillation dose is achieved in a low

  9. External validity of the pediatric cardiac quality of life inventory

    PubMed Central

    Marino, Bradley S.; Drotar, Dennis; Cassedy, Amy; Davis, Richard; Tomlinson, Ryan S.; Mellion, Katelyn; Mussatto, Kathleen; Mahony, Lynn; Newburger, Jane W.; Tong, Elizabeth; Cohen, Mitchell I.; Helfaer, Mark A.; Kazak, Anne E.; Wray, Jo; Wernovsky, Gil; Shea, Judy A.; Ittenbach, Richard

    2012-01-01

    Purpose The Pediatric Cardiac Quality of Life Inventory (PCQLI) is a disease-specific, health-related quality of life (HRQOL) measure for pediatric heart disease (HD). The purpose of this study was to demonstrate the external validity of PCQLI scores. Methods The PCQLI development site (Development sample) and six geographically diverse centers in the United States (Composite sample) recruited pediatric patients with acquired or congenital HD. Item response option variability, scores [Total (TS); Disease Impact (DI) and Psychosocial Impact (PI) subscales], patterns of correlation, and internal consistency were compared between samples. Results A total of 3,128 patients and parent participants (1,113 Development; 2,015 Composite) were analyzed. Response option variability patterns of all items in both samples were acceptable. Inter-sample score comparisons revealed no differences. Median item–total (Development, 0.57; Composite, 0.59) and item–subscale (Development, DI 0.58, PI 0.59; Composite, DI 0.58, PI 0.56) correlations were moderate. Subscale–subscale (0.79 for both samples) and subscale–total (Development, DI 0.95, PI 0.95; Composite, DI 0.95, PI 0.94) correlations and internal consistency (Development, TS 0.93, DI 0.90, PI 0.84; Composite, TS 0.93, DI 0.89, PI 0.85) were high in both samples. Conclusion PCQLI scores are externally valid across the US pediatric HD population and may be used for multi-center HRQOL studies. PMID:21188538

  10. The compromised inflammatory response to bacterial components after pediatric cardiac surgery is associated with cardiopulmonary bypass-suppressed Toll-like receptor signal transduction pathways.

    PubMed

    Li, Yi-ping; Huang, Jie; Huang, Shun-gen; Xu, Yong-gen; Xu, Yun-yun; Liao, Jian-yi; Feng, Xing; Zhang, Xue-guang; Wang, Jiang Huai; Wang, Jian

    2014-04-01

    Cardiopulmonary bypass (CPB) during pediatric cardiac surgery often elicits a systemic inflammatory response followed by a compromised immune response, which has been attributed to the morbidity of postoperative infection; however, the underlying mechanism(s) has not yet been fully elucidated. We hypothesized that CPB inhibits the activation of Toll-like receptor (TLR) signal transduction pathways, thereby causing an immunosuppressive state after pediatric cardiac surgery. We examined 20 children with congenital heart disease undergoing pediatric cardiac surgery. Cardiopulmonary bypass differentially affected lipopolysaccharide (LPS)- or bacterial lipoprotein (BLP)-stimulated ex vivo production of proinflammatory and anti-inflammatory cytokines, with significantly diminished tumor necrosis factor α, interleukin (IL) 1β, IL-6, and IL-8, but substantially enhanced IL-10 production. Consistent with the reduced inflammatory response, CPB strongly inhibited LPS- or BLP-activated TLR signal transduction pathways in monocytes with down-regulated expression of CD14, TLR4, and TLR2 and with suppressed phosphorylation of nuclear factor κB p65, p38, and extracellular signal-regulated kinase 1/2. These results indicate that CPB during pediatric cardiac surgery causes substantially reduced production of inflammatory cytokines in response to bacterial component LPS or BLP stimulation, which is associated with CPB-induced suppression of TLR-mediated signal transduction pathways. This reduced inflammatory response after CPB in children with congenital heart disease may predispose them to an increased risk of postoperative infection. © 2014.

  11. The department of psychology within a pediatric cardiac transplant unit.

    PubMed

    Rossi, A; De Ranieri, C; Tabarini, P; Di Ciommo, V; Di Donato, R; Biondi, G; Parisi, F

    2011-05-01

    In 1979, the department of Psychology started its activity to provide psychological support to patients and their families during the course of treatment and during the follow-up period. Since 1986, a transplantation program was initiated in the cardiology and pediatric cardiac surgery departments, performing 179 cardiac, 3 heart-kidney, 18 heart-lung 14 both lung, 1 heart-lung-liver, and 1 single lung transplantation. From 1993, to September 2010 the kidney transplant program has performed. 218 cases. Since 2008, we performed (32 liver and 1 intestinal transplantations). We examined the quality of life and coping with transplantation attitudes because there is recent evidence of high levels of family anxiety and depression related to a child's poor response to the disease and compliance. Our work associated post-traumatic stress disorder (PTSD) with anxiety and with these clinical variables: gender pathology, rejection, number of drugs frequency of hospital visits, number of hospitalizations, as well as age at and time from transplantation. We examined 56 parents (25 fathers and 31 mothers) of cardiac transplant recipients. Our most relevant data demonstrated the presence of PTSD among 52% of mothers and 40% of fathers. Significant correlations were observed within the trait of anxiety. No correlations were noted between PTSD and other variables. Testing anxiety levels of parents is considered to be basic to provide psychological support to parents, encourage personal skills, and avoid PTSD symptoms. Copyright © 2011 Elsevier Inc. All rights reserved.

  12. Postoperative keratitis due to Paecilomyces: a rare pediatric case

    PubMed Central

    Toker, Ebru; Ziyade, Nihan; Atici, Serkan; Eda, Kepenekli Kadayifçi; Türel, Özden; Toprak, Demet; Oray, Merih; Cerikcioglu, Nilgün; Soysal, Ahmet; Bakir, Mustafa

    2016-01-01

    Fungal infections like Paecilomyces keratitis have emerged in childhood recently. The diagnosis and treatment of Paecilomyces keratitis is difficult and the outcome is usually poor. Corneal culture should be performed on fungal media such as Sabouraud glucose neopeptone agar (SDA) as soon as possible for diagnosis. We report a rare case of Paecilomyces keratitis in an immunocompetent child, which was unresponsive to amphotericin B. The case was managed by a multidisciplinary approach involving the departments of ophthalmology, microbiology and pediatric infectious diseases. We want to draw attention once again that fungal keratitis caused by unusual agents are increasing. Physicians should consider fungal causes of keratitis, in patients with some predisposing factors like ocular surgery and prolonged use of topical corticosteroids. PMID:28154672

  13. The use of recombinant coagulation factor VIIa in uncontrolled postoperative bleeding in children undergoing cardiac surgery with cardiopulmonary bypass.

    PubMed

    Pychyńska-Pokorska, Magdalena; Moll, Jacek Jan; Krajewski, Wojciech; Jarosik, Piotr

    2004-05-01

    To assess the hemostatic efficacy of recombinant coagulation factor VIIa (rFVIIa) in the management of uncontrolled bleeding in postcardiac surgery with cardiopulmonary bypass in children. An open-label study. A postoperative intensive care unit. Eight consecutive pediatric patients with excessive bleeding after cardiac surgery with cardiopulmonary bypass that met the criteria for reexploration and did not respond to optimal transfusions of platelets and fresh frozen plasma. rFVIIa 30 microg/kg was given as a bolus injection. A higher dose of 60 microg/kg was used if a patient had preoperative coagulopathy, preoperative multiple-organ failure, or indications that required an emergency operation. The same dose was repeated 15 mins after the previous injection if the bleeding had not decreased. If the bleeding had decreased but still exceeded 10 mL/hr for body weight 5 kg, the same dose was repeated 2 hrs after the previous injection. A maximum of four doses could be given before rFVIIa was considered ineffective and a reexploration was needed. Postoperative blood loss was estimated from the volume of chest tube drainage. rFVIIa successfully controlled bleeding and prevented reexploration in all seven patients who received treatment according to the protocol. One patient who received only one dose of rFVIIa required reexploration because a second dose was not available. No adverse events related to rFVIIa were seen. rFVIIa may be useful in preventing reexploration in uncontrolled postoperative bleeding in children undergoing cardiac surgery with cardiopulmonary bypass. Randomized, placebo-controlled studies are needed to confirm the safety and efficacy of rFVIIa in this clinical setting.

  14. Department of Pediatric Cardiac Surgery in Gdansk in its new location – previous activity and perspectives for development

    PubMed Central

    Chojnicki, Maciej; Steffens, Mariusz; Jaworski, Radosław; Szofer-Sendrowska, Aneta; Paczkowski, Konrad; Kwaśniak, Ewelina; Romanowicz, Anna; Szymanowicz, Wiktor; Gierat-Haponiuk, Katarzyna

    2017-01-01

    The Department of Pediatric Cardiac Surgery in Gdansk is the only pediatric cardiac surgery center in northern Poland providing comprehensive treatment to children with congenital heart defects. The Department of Pediatric Cardiac Surgery in Gdansk currently offers a full spectrum of advanced procedures of modern cardiac surgery and interventional cardiology dedicated to patients from infancy to adolescence. January 19, 2016 marked the official opening of its new location. PMID:28515759

  15. Vitamin C for the Prevention of Postoperative Atrial Fibrillation after Cardiac Surgery: A Meta-Analysis

    PubMed Central

    Polymeropoulos, Evangelos; Bagos, Pantelis; Papadimitriou, Maria; Rizos, Ioannis; Patsouris, Efstratios; Τoumpoulis, Ioannis

    2016-01-01

    Purpose: Several studies have investigated the administration of vitamin C (vitC) for the prevention of postoperative atrial fibrillation (AF) after cardiac surgery. However, their findings were inconsistent. The purpose of this meta-analysis was to evaluate the efficacy of vitC as prophylaxis for the prevention of postoperative AF in cardiac surgery. Methods: A systematic search of PubMed, EMBASE, Google Scholar, the Cochrane Library, and clinical trial registries, was performed. 9 studies, published from August 2001 to May 2015, were included, with a total of 1,037 patients. Patients were randomized to receive vitC, or placebo. Results: Cardiac surgery patients who received vitC as prophylaxis, had a significantly lower incidence of postoperative AF (random effects OR=0.478, 95% CI 0.340 – 0.673, P < 10-4). No significant heterogeneity was detected across the analyzed studies (I2=21.7%), and no publication bias or other small study-related bias was found. Conclusion: Our findings suggest that VitC is effective as prophylaxis for the prevention of postoperative AF. The administration of vitC may be considered in all patients undergoing cardiac surgery. PMID:27478787

  16. Comparison of Transcutaneous Electrical Nerve Stimulation and Parasternal Block for Postoperative Pain Management after Cardiac Surgery.

    PubMed

    Ozturk, Nilgun Kavrut; Baki, Elif Dogan; Kavakli, Ali Sait; Sahin, Ayca Sultan; Ayoglu, Raif Umut; Karaveli, Arzu; Emmiler, Mustafa; Inanoglu, Kerem; Karsli, Bilge

    2016-01-01

    Background. Parasternal block and transcutaneous electrical nerve stimulation (TENS) have been demonstrated to produce effective analgesia and reduce postoperative opioid requirements in patients undergoing cardiac surgery. Objectives. To compare the effectiveness of TENS and parasternal block on early postoperative pain after cardiac surgery. Methods. One hundred twenty patients undergoing cardiac surgery were enrolled in the present randomized, controlled prospective study. Patients were assigned to three treatment groups: parasternal block, intermittent TENS application, or a control group. Results. Pain scores recorded 4 h, 5 h, 6 h, 7 h, and 8 h postoperatively were lower in the parasternal block group than in the TENS and control groups. Total morphine consumption was also lower in the parasternal block group than in the TENS and control groups. It was also significantly lower in the TENS group than in the control group. There were no statistical differences among the groups regarding the extubation time, rescue analgesic medication, length of intensive care unit stay, or length of hospital stay. Conclusions. Parasternal block was more effective than TENS in the management of early postoperative pain and the reduction of opioid requirements in patients who underwent cardiac surgery through median sternotomy. This trial is registered with Clinicaltrials.gov number NCT02725229.

  17. Viscoelastic blood coagulation measurement with Sonoclot predicts postoperative bleeding in cardiac surgery after heparin reversal.

    PubMed

    Bischof, Dominique B; Ganter, Michael T; Shore-Lesserson, Linda; Hartnack, Sonja; Klaghofer, Richard; Graves, Kirk; Genoni, Michele; Hofer, Christoph K

    2015-01-01

    The aim of the study was to determine if Sonoclot with its sensitive glass bead-activated, viscoelastic test can predict postoperative bleeding in patients undergoing cardiac surgery at predefined time points. A prospective, observational clinical study. A teaching hospital, single center. Consecutive patients undergoing cardiac surgery (N = 300). Besides routine laboratory coagulation studies and heparin management with standard (kaolin) activated clotting time, additional native blood samples were analyzed on a Sonoclot using glass bead-activated tests. Glass bead-activated clotting time, clot rate, and platelet function were recorded immediately before anesthesia induction and at the end of surgery after heparin reversal but before chest closure. Primary outcome was postoperative blood loss (chest tube drainage at 4, 8, and 12 hours postoperatively). Secondary outcome parameters were transfusion requirements, need for surgical re-exploration, time of mechanical ventilation, length of intensive care unit and hospital stay, and hospital morbidity and mortality. Patients were categorized into "bleeders" and "nonbleeders." Patient characteristics, operations, preoperative standard laboratory parameters, and procedural times were comparable between bleeders and nonbleeders except for sex and age. Bleeders had higher rates of transfusions, surgical re-explorations, and complications. Only glass bead measurements by Sonoclot after heparin reversal before chest closure but not preoperatively were predictive for increased postoperative bleeding. Sonoclot with its glass bead-activated tests may predict the risk for postoperative bleeding in patients undergoing cardiac surgery at the end of surgery after heparin reversal but before chest closure. Copyright © 2015 Elsevier Inc. All rights reserved.

  18. Incidence, Predictors, and Clinical Outcomes of Postoperative Cardiac Tamponade in Patients Undergoing Heart Valve Surgery.

    PubMed

    You, Seng Chan; Shim, Chi Young; Hong, Geu-Ru; Kim, Darae; Cho, In Jeong; Lee, Sak; Chang, Hyuck-Jae; Ha, Jong-Won; Chang, Byung-Chul; Chung, Namsik

    2016-01-01

    This study aimed to investigate the incidence, predictors, and clinical outcomes of cardiac tamponade after heart valve surgery. A total of 556 patients who underwent heart valve surgery in a single tertiary center between January 2010 and March 2012 were studied. All patients underwent transthoracic echocardiography (TTE) about 5 days after surgery and TTE was repeated regularly. Patients with suspected acute pericardial hemorrhage were excluded. Cardiac tamponade occurred in twenty-four (4.3%) patients and all underwent surgical or percutaneous pericardial drainage. The median time of pericardial drainage after surgery was 17 (interquartile range, IQR, 13-30) days. Infective endocarditis, mechanical valve replacement of aortic or mitral valve, and any amount of pericardial effusion (PE) on the first postoperative TTE were related to the occurrence of cardiac tamponade (all p<0.05). After multivariate adjustment, occurrence of cardiac tamponade was associated with any amount of PE on the first postoperative TTE (hazard ratio, HR, 14.00, p<0.001) and mechanical valve replacement (HR 2.69, p = 0.025). The mean hospital days in patients with cardiac tamponade was higher than those without (34.9 vs. 13.5, p = 0.031). After pericardial drainage, there was no echocardiographic recurrence of significant PE during a median of 34.8 (IQR 14.9-43.7) months after surgery. Cardiac tamponade after heart valve surgery is not uncommon. Patients with any amount of PE at the first postoperative TTE or mechanical valve replacement should receive higher attention with regard to the occurrence of cardiac tamponade. Although it prolongs hospital stay, cardiac tamponade exhibits a benign clinical course without recurrence after timely intervention.

  19. One-Year Mortality, Causes of Death, and Cardiac Interventions in Patients with Postoperative Myocardial Injury.

    PubMed

    van Waes, Judith A R; Grobben, Remco B; Nathoe, Hendrik M; Kemperman, Hans; de Borst, Gert Jan; Peelen, Linda M; van Klei, Wilton A

    2016-07-01

    To evaluate the role of routine troponin surveillance in patients undergoing major noncardiac surgery, unblinded screening with cardiac consultation per protocol was implemented at a tertiary care center. In this study, we evaluated 1-year mortality, causes of death, and consequences of cardiac consultation of this protocol. This observational cohort included 3224 patients ≥60 years old undergoing major noncardiac surgery. Troponin I was measured routinely on the first 3 postoperative days. Myocardial injury was defined as troponin I >0.06 μg/L. Regression analysis was used to determine the association between myocardial injury and 1-year mortality. The causes of death, the diagnoses of the cardiologists, and interventions were determined for different levels of troponin elevation. Postoperative myocardial injury was detected in 715 patients (22%) and was associated with 1-year all-cause mortality (relative risk [RR] 1.4, P = 0.004; RR 1.6, P < 0.001; and RR 2.2, P < 0.001 for minor, moderate, and major troponin elevation, respectively). Cardiac death within 1 year occurred in 3%, 5%, and 11% of patients, respectively, in comparison with 3% of the patients without myocardial injury (P = 0.059). A cardiac consultation was obtained in 290 of the 715 patients (41%). In 119 (41%) of these patients, the myocardial injury was considered to be attributable to a predisposing cardiac condition, and in 111 patients (38%), an intervention was initiated. Postoperative myocardial injury was associated with an increased risk of 1-year all-cause but not cardiac mortality. A cardiac consultation with intervention was performed in less than half of these patients. The small number of interventions may be explained by a low suspicion of a cardiac etiology in most patients and lack of consensus for standardized treatment in these patients.

  20. Incidence, Predictors, and Clinical Outcomes of Postoperative Cardiac Tamponade in Patients Undergoing Heart Valve Surgery

    PubMed Central

    You, Seng Chan; Shim, Chi Young; Hong, Geu-Ru; Kim, Darae; Cho, In Jeong; Lee, Sak; Chang, Hyuck-Jae; Ha, Jong-Won; Chang, Byung-Chul; Chung, Namsik

    2016-01-01

    This study aimed to investigate the incidence, predictors, and clinical outcomes of cardiac tamponade after heart valve surgery. A total of 556 patients who underwent heart valve surgery in a single tertiary center between January 2010 and March 2012 were studied. All patients underwent transthoracic echocardiography (TTE) about 5 days after surgery and TTE was repeated regularly. Patients with suspected acute pericardial hemorrhage were excluded. Cardiac tamponade occurred in twenty-four (4.3%) patients and all underwent surgical or percutaneous pericardial drainage. The median time of pericardial drainage after surgery was 17 (interquartile range, IQR, 13–30) days. Infective endocarditis, mechanical valve replacement of aortic or mitral valve, and any amount of pericardial effusion (PE) on the first postoperative TTE were related to the occurrence of cardiac tamponade (all p<0.05). After multivariate adjustment, occurrence of cardiac tamponade was associated with any amount of PE on the first postoperative TTE (hazard ratio, HR, 14.00, p<0.001) and mechanical valve replacement (HR 2.69, p = 0.025). The mean hospital days in patients with cardiac tamponade was higher than those without (34.9 vs. 13.5, p = 0.031). After pericardial drainage, there was no echocardiographic recurrence of significant PE during a median of 34.8 (IQR 14.9–43.7) months after surgery. Cardiac tamponade after heart valve surgery is not uncommon. Patients with any amount of PE at the first postoperative TTE or mechanical valve replacement should receive higher attention with regard to the occurrence of cardiac tamponade. Although it prolongs hospital stay, cardiac tamponade exhibits a benign clinical course without recurrence after timely intervention. PMID:27855225

  1. Postoperative Electroencephalogram for Follow up of Pediatric Moyamoya Disease

    PubMed Central

    Kim, Deok-Soo; Ra, Young-Shin; Choi, Choong-Gon

    2006-01-01

    It is well known that the electroencephalographic finding in patients with moyamoya disease demonstrates the characteristic "re-build up" phenomenon a few minutes after hyperventilation. To evaluate the usefulness of an electroencephalogram (EEG) in the postoperative management of children with moyamoya disease, we studied the presence or absence of improvement in the clinical, single photon emission computed tomography (SPECT) and EEG findings, before and after surgery. Twenty-two patients, who underwent indirect revascularization surgery for moyamoya disease, were included in our study. Clinical improvement was assessed as the disappearance or decrease of a transient ischemic attack or headache. The findings on the EEG and SPECT were considered improved when the re-build up phenomenon was absent and when there was improvement in the cerebrovascular reserve as a result of the acetazolamide challenge test. The statistical correlation analysis for both clinical and EEG improvement were consistent (kappa value=0.409, p<0.05). However, the result from the clinical and SPECT improvement as well as that from EEG and SPECT improvement were not statistically significant. Our results suggest that EEG can be used as a noninvasive and simple follow-up test for moyamoya disease after indirect revascularization surgery if the hyperventilation procedure is effectively performed during EEG recording. PMID:16778396

  2. Rationale for Implementation of Warm Cardiac Surgery in Pediatrics

    PubMed Central

    Durandy, Yves

    2016-01-01

    Cardiac surgery was developed thanks to the introduction of hypothermia and cardiopulmonary bypass in the early 1950s. The deep hypothermia protective effect has been essential to circulatory arrest complex cases repair. During the early times of open-heart surgery, a major concern was to decrease mortality and to improve short-term outcomes. Both mortality and morbidity dramatically decreased over a few decades. As a consequence, the drawbacks of deep hypothermia, with or without circulatory arrest, became more and more apparent. The limitation of hypothermia was particularly evident for the brain and regional perfusion was introduced as a response to this problem. Despite a gain in popularity, the results of regional perfusion were not fully convincing. In the 1990s, warm surgery was introduced in adults and proved to be safe and reliable. This option eliminates the deleterious effect of ischemia–reperfusion injuries through a continuous, systemic coronary perfusion with warm oxygenated blood. Intermittent warm blood cardioplegia was introduced later, with impressive results. We were convinced by the easiness, safety, and efficiency of warm surgery and shifted to warm pediatric surgery in a two-step program. This article outlines the limitations of hypothermic protection and the basic reasons that led us to implement pediatric warm surgery. After tens of thousands of cases performed across several centers, this reproducible technique proved a valuable alternative to hypothermic surgery. PMID:27200324

  3. Factors affecting recovery of postoperative bowel function after pediatric laparoscopic surgery

    PubMed Central

    Michelet, Daphnée; Andreu-Gallien, Juliette; Skhiri, Alia; Bonnard, Arnaud; Nivoche, Yves; Dahmani, Souhayl

    2016-01-01

    Background and Aims: Laparoscopic pediatric surgery allows a rapid postoperative rehabilitation and hospital discharge. However, the optimal postoperative pain management preserving advantages of this surgical technique remains to be determined. This study aimed to identify factors affecting the postoperative recovery of bowel function after laparoscopic surgery in children. Material and Methods: A retrospective analysis of factors affecting recovery of bowel function in children and infants undergoing laparoscopic surgery between January 1, 2009 and September 30, 2009, was performed. Factors included were: Age, weight, extent of surgery (extensive, regional or local), chronic pain (sickle cell disease or chronic intestinal inflammatory disease), American Society of Anaesthesiologists status, postoperative analgesia (ketamine, morphine, nalbuphine, paracetamol, nonsteroidal anti-inflammatory drugs [NSAIDs], nefopam, regional analgesia) both in the Postanesthesia Care Unit and in the surgical ward; and surgical complications. Data analysis used classification and regression tree analysis (CART) with a 10-fold cross validation. Results: One hundred and sixty six patients were included in the analysis. Recovery of bowel function depended upon: The extent of surgery, the occurrence of postoperative surgical complications, the administration of postoperative morphine in the surgical ward, the coadministration of paracetamol and NSAIDs and/or nefopam in the surgical ward and the emergency character of the surgery. The CART method generated a decision tree with eight terminal nodes. The percentage of explained variability of the model and the cross validation were 58% and 49%, respectively. Conclusion: Multimodal analgesia using nonopioid analgesia that allows decreasing postoperative morphine consumption should be considered for the speed of bowel function recovery after laparoscopic pediatric surgery. PMID:27625488

  4. Utility of Postoperative Antibiotics After Percutaneous Pinning of Pediatric Supracondylar Humerus Fractures.

    PubMed

    Schroeder, Nicholas O; Seeley, Mark A; Hariharan, Arun; Farley, Frances A; Caird, Michelle S; Li, Ying

    2017-09-01

    Pediatric supracondylar humerus fractures are common injuries that are often treated surgically with closed reduction and percutaneous pinning. Although surgical-site infections are rare, postoperative antibiotics are frequently administered without evidence or guidelines for their use. With the increasing prevalence of antibiotic-resistant organisms and heightened focus on health care costs, appropriate and evidence-based use of antibiotics is needed. We hypothesized that postoperative antibiotic administration would not decrease the rate of surgical-site infection. A billing query identified 951 patients with operatively treated supracondylar humerus fractures at our institution over a 15-year period. Records were reviewed for demographic data, perioperative antibiotic use, and the presence of surgical-site infection. Exclusion criteria were open fractures, open reduction, pathologic fractures, metabolic bone disease, the presence of other injuries that required operative treatment, and follow-up <2 weeks after pin removal. χ and Fisher exact test were used to compare antibiotic use to the incidence of surgical-site infection. Six hundred eighteen patients met our inclusion criteria. Two hundred thirty-eight patients (38.5%) received postoperative antibiotics. Eleven surgical-site infections were identified for an overall rate of 1.8%. The use of postoperative antibiotics was not associated with a lower rate of surgical-site infection (P=0.883). Patients with a type III fracture (P<0.001), diminished preoperative vascular (P=0.001) and neurological status (P=0.019), and postoperative hospital admission (P<0.001) were significantly more likely to receive postoperative antibiotics. Administration of postoperative antibiotics after closed reduction and percutaneous pinning of pediatric supracondylar humerus fractures does not decrease the rate of surgical-site infection. Level III-therapeutic.

  5. The impact of prenatal diagnosis of congenital heart disease on pediatric cardiology and cardiac surgery.

    PubMed

    Chiappa, Enrico

    2007-01-01

    Since the early 1980s prenatal diagnosis of congenital heart disease (CHD) has progressively impacted on the practice of pediatric cardiology and cardiac surgery. Fetal cardiology today raises special needs in screening programs, training of the involved staff, and allocations of services. Due to the increased detection rate and to the substantial number of terminations, the reduced incidence of CHD at birth can affect the workload of centers of pediatric cardiology and surgery. In utero transportation and competition among centers may change the area of referral in favor of the best centers. Echocardiography is a powerful means to diagnose and to guide lifesaving medical treatment of sustained tachyarrhythmias in the fetus. Prenatal diagnosis not only improves the preoperative conditions in most cases but also postoperative morbidity and mortality in selected types of CHD. Intrauterine transcatheter valvuloplasty in severe outflow obstructive lesions has been disappointing so far and this technique remains investigational, until its benefits are determined by controlled trials. Prenatal diagnosis allows counselling of families which are better prepared for the foreseeable management and outcome of the fetus. These benefits can reduce the risks of litigation for missed ultrasound diagnosis. As increased costs can be expected in institutions dealing with a large number of fetal CHD, the administrators of these institutions should receive protected funds, proportional to their needs.

  6. Music benefits on postoperative distress and pain in pediatric day care surgery.

    PubMed

    Calcaterra, Valeria; Ostuni, Selene; Bonomelli, Irene; Mencherini, Simonetta; Brunero, Marco; Zambaiti, Elisa; Mannarino, Savina; Larizza, Daniela; Albertini, Riccardo; Tinelli, Carmine; Pelizzo, Gloria

    2014-08-12

    Postoperative effect of music listening has not been established in pediatric age. Response on postoperative distress and pain in pediatric day care surgery has been evaluated. Forty-two children were enrolled. Patients were randomly assigned to the music-group (music intervention during awakening period) or the non-music group (standard postoperative care). Slow and fast classical music and pauses were recorded and played via ambient speakers. Heart rate, blood pressure, oxygen saturation, glucose and cortisol levels, faces pain scale and Face, Legs, Activity, Cry, Consolability (FLACC) Pain Scale were considered as indicators of response to stress and pain experience. Music during awakening induced lower increase of systolic and diastolic blood pressure levels. The non-music group showed progressive increasing values of glycemia; in music-group the curve of glycemia presented a plateau pattern (P<0.001). Positive impact on reactions to pain was noted using the FLACC scale. Music improves cardiovascular parameters, stress-induced hyperglycemia. Amelioration on pain perception is more evident in older children. Positive effects seems to be achieved by the alternation of fast, slow rhythms and pauses even in pediatric age.

  7. Music Benefits on Postoperative Distress and Pain in Pediatric Day Care Surgery

    PubMed Central

    Calcaterra, Valeria; Ostuni, Selene; Bonomelli, Irene; Mencherini, Simonetta; Brunero, Marco; Zambaiti, Elisa; Mannarino, Savina; Larizza, Daniela; Albertini, Riccardo; Tinelli, Carmine; Pelizzo, Gloria

    2014-01-01

    Postoperative effect of music listening has not been established in pediatric age. Response on postoperative distress and pain in pediatric day care surgery has been evaluated. Forty-two children were enrolled. Patients were randomly assigned to the music-group (music intervention during awakening period) or the non-music group (standard postoperative care). Slow and fast classical music and pauses were recorded and played via ambient speakers. Heart rate, blood pressure, oxygen saturation, glucose and cortisol levels, faces pain scale and Face, Legs, Activity, Cry, Consolability (FLACC) Pain Scale were considered as indicators of response to stress and pain experience. Music during awakening induced lower increase of systolic and diastolic blood pressure levels. The non-music group showed progressive increasing values of glycemia; in music-group the curve of glycemia presented a plateau pattern (P<0.001). Positive impact on reactions to pain was noted using the FLACC scale. Music improves cardiovascular parameters, stress-induced hyperglycemia. Amelioration on pain perception is more evident in older children. Positive effects seems to be achieved by the alternation of fast, slow rhythms and pauses even in pediatric age. PMID:25635217

  8. Alternative Approach to the Management of Postoperative Pain after Pediatric Surgical Procedures

    PubMed Central

    Souza, Juliana; Santos-Pinto, Lourdes; Pansani, Cyneu

    2014-01-01

    ABSTRACT Aim: This paper reports two clinical cases in which the application of low-level laser therapy (LLLT) enhanced the postoperative symptoms after pediatric surgical procedures. Background: The uses of novel technologies allow more comfort to the patients and ensure a rapid procedure, and LLLT application has shown a positive effect in the prevention of discomfort after invasive procedures. Case description: Low-level laser therapy protocol was applied after surgical removal of supernumerary tooth and frenectomy resulting in less swallow and pain with no need of medication intake. Conclusion: The laser application was well accepted by both children and parents and showed a clinical efficiency in the follow-up examinations beyond the satisfactory quality of wound healing. Clinical significance: The LLLT approach is an excellent adjuvant therapy resource for delivery an optimal postoperative after surgical procedures in children. How to cite this article: Paschoal M, Souza J, Santos-Pinto L, Pansani C. Alternative Approach to the Management of Postoperative Pain after Pediatric Surgical Procedures. Int J Clin Pediatr Dent 2014;7(2):125-129. PMID:25356012

  9. Acupressure wristbands for the prevention of postoperative nausea and vomiting in adults undergoing cardiac surgery.

    PubMed

    Klein, Andrew A; Djaiani, George; Karski, Jacek; Carroll, Jo; Karkouti, Keyvan; McCluskey, Stuart; Poonawala, Humara; Shayan, Charles; Fedorko, Ludwik; Cheng, Davy

    2004-02-01

    To determine whether the application of acupressure bands would lead to a reduction in postoperative nausea and vomiting after cardiac surgery. Prospective, randomized, double-blind clinical trial. University-affiliated tertiary care teaching hospital. Adult patients undergoing cardiac surgery. One hundred fifty-two patients were enrolled to receive either acupressure treatment (n = 75) or placebo (n = 77). All patients had acupressure bands placed on both wrists before induction of anesthesia; those in the treatment group had a bead placed in contact with the P6 point on the forearm. Patients were assessed for nausea, vomiting, and pain scores during the first 24 hours of the postoperative period. The incidences of nausea, vomiting, pain scores, and analgesic and antiemetic requirements were similar between the 2 groups. A subgroup analysis by gender implied that acupressure treatment may be effective only in female patients. Acupressure treatment did not lead to a reduction in nausea, vomiting, or antiemetic requirements in patients after cardiac surgery.

  10. Prevalence and Risk Factors for Pericardial Effusions Requiring Readmission After Pediatric Cardiac Surgery.

    PubMed

    Elias, Matthew D; Glatz, Andrew C; O'Connor, Matthew J; Schachtner, Susan; Ravishankar, Chitra; Mascio, Christoper E; Cohen, Meryl S

    2017-03-01

    Pericardial effusion (PE) may require readmission after cardiac surgery and has been associated with postoperative morbidity and mortality. We sought to identify the prevalence and risk factors for postoperative PE requiring readmission in children. A retrospective analysis of the Pediatric Health Information System database was performed between January 1, 2003, and September 30, 2014. All patients ≤18 years old who underwent cardiac surgery were identified by ICD-9 codes. Those readmitted within 1 year with an ICD-9 code for PE were identified. Logistic regression analysis was performed to determine risk factors for PE readmissions. Of the 142,633 surgical admissions, 1535 (1.1%) were readmitted with PE. In multivariable analysis, older age at the initial surgical admission [odds ratio (OR) 1.17, p < 0.001], trisomy 21 (OR 1.24, p = 0.015), geographic region (OR 1.33-1.48, p ≤ 0.001), and specific surgical procedures [heart transplant (OR 1.82, p < 0.001), systemic-pulmonary artery shunt (OR 2.23, p < 0.001), and atrial septal defect surgical repair (OR 1.34, p < 0.001)] were independent risk factors for readmission with PE. Of readmitted patients, 44.2% underwent an interventional PE procedure. Factors associated with interventions included shorter length of stay (LOS) for the initial surgical admission (OR 0.85, p = 0.008), longer LOS for the readmission (OR 1.37, p < 0.001), and atrial septal defect surgery (OR 1.40, p = 0.005). In this administrative database of children undergoing cardiac surgery, readmissions for PE occurred after 1.1% of cardiac surgery admissions. The risk factors identified for readmissions and interventions may allow for improved risk stratification, family counseling, and earlier recognition of PE for children undergoing cardiac surgery.

  11. Pediatric Mechanical Support with an External Cardiac Compression Device

    PubMed Central

    Kavarana, Minoo N; Loree, Howard M; Stewart, Robert B; Milbocker, Michael T; Hannan, Robert L; Pantalos, George M; Kung, Robert TV

    2013-01-01

    The PediBooster external cardiac compression device is a minimally invasive, non-blood contacting Biventricular Assist Device (BiVAD) intended for pediatric use. It is being developed as a palliative therapy for acute Postcardiotomy Shock (PCS). The PediBooster extracardiac wrap is pneumatically actuated to circumferentially compress the heart, providing co-pulsation support. Attachment is via a novel hydrogel coating. Early versions of the wrap were tested in vivo using a single ventricle congenital heart disease model with postcardiotomy shock, which proved unstable and demonstrated high peri-operative mortality. The final wrap design was tested in 4 acute studies with piglets (5.1 ± 0.3 kg), where the combination of ASD and PA banding induced acute right ventricular dysfunction. Data collected included routine hemodynamic values, TEE, video of the exposed heart, and cardiac histology. The model proved stable for support durations ranging from 2 to 16 hours. The wrap restricted the heart in 3 of the 4 animals, as evidenced by increased diastolic LVP during support compared to the baseline failure condition. TEE and video data showed good attachment and function of the wrap, particularly during the final 16 hr study. This model of congenital heart disease shows promise for chronic (24-72 hr) studies. Ventricular filling during support may be improved by adjusting wrap dimensions to eliminate end diastolic restriction. PMID:24040624

  12. Risk factors, morbidity, and mortality associated with atrial fibrillation in the postoperative period of cardiac surgery.

    PubMed

    Silva, Rogério Gomes da; Lima, Gustavo Glotz de; Laranjeira, Andréia; Costa, Altamiro Reis da; Pereira, Edemar; Rodrigues, Rubem

    2004-08-01

    To determine the incidence of atrial fibrillation in the postoperative period of cardiac surgery, its impact on morbidity, mortality, and hospital stay, and to analyze the risk factors in the pre, trans, and postoperative periods. Contemporary cohort study with 158 adult patients undergoing cardiac surgery, of whom those with atrial fibrillation in the preoperative period were excluded. The patients were assessed with continuous cardiac monitoring and daily electrocardiograms. Any episode of irregular rhythm with the presence of f waves of variable morphology and amplitude was considered atrial fibrillation. The general incidence of atrial fibrillation was 28.5%, being 21.6% for revascularized patients and 44.3% for those undergoing valvular repair. Factors independently associated with atrial fibrillation were left heart failure in the preoperative period (p=0.05; RC=2.2), total fluid balance (p=0.01; RC=1.0), duration of surgery (p=0.03; RC=1.01) [and other associated factors, age > 70 years, aortic valvular disease, psychomotor agitation, length of installation of the drains, pulmonary congestion and respiratory insufficiency in the postoperative period]. The use of beta-blockers (p=0.01; RC=0.3) was a protective factor. Atrial fibrillation in the postoperative period was associated with an increase in the length of hospital stay (16.9+/-12.3 days versus 9.2+/-4.0 days, p<0.001) and a greater incidence of stroke or postoperative death (p=0.02). The incidence of atrial fibrillation in the postoperative period of cardiac surgery was high and caused a significant increase in morbidity, mortality, and the length of hospital stay. Among the independent risk factors, excessive fluid balance is significant. The use of beta-blockers was identified as a protective factor.

  13. Circulating cardiac biomarkers and postoperative atrial fibrillation in the OPERA trial.

    PubMed

    Masson, Serge; Wu, Jason H Y; Simon, Caterina; Barlera, Simona; Marchioli, Roberto; Mariani, Javier; Macchia, Alejandro; Lombardi, Federico; Vago, Tarcisio; Aleksova, Aneta; Dreas, Lorella; Favaloro, Roberto R; Hershson, Alejandro R; Puskas, John D; Dozza, Luca; Silletta, Maria G; Tognoni, Gianni; Mozaffarian, Dariush; Latini, Roberto

    2015-02-01

    Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and predicts increased morbidity and mortality. Identification of patients at high risk of POAF with the help of circulating biomarkers may enable early preventive treatment but data are limited, especially in contemporary surgical patients. Plasma concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) were measured at enrollment, on the morning of cardiac surgery, at end surgery, and 2 days postsurgery in 562 patients undergoing cardiac surgery, randomized to perioperative supplementation with oral fish oil or placebo in the Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation trial (OPERA). The primary endpoint was incident POAF lasting ≥ 30 s, centrally adjudicated and confirmed electrocardiographically. Higher levels of NT-proBNP and hs-cTnT before surgery were associated with older age, renal or cardiac dysfunction and EuroSCORE. NT-proBNP peaked on postoperative day 2 (2172 [1238-3758] ng/L, median [Q1-Q3]), while hs-cTnT peaked at the end of surgery (373 [188-660] ng/L). Fish oil supplementation did not alter the time course of the cardiac biomarkers (P > 0.05). Concentrations of NT-proBNP or hs-cTnT, on the morning of surgery, or changes in their level between morning of surgery and postsurgery, were not significantly associated with POAF after adjustment for clinical and surgical characteristics. Among patients undergoing cardiac surgery, NT-proBNP and hs-cTnT are related to clinical and surgical characteristics, have different perioperative time courses but are not independently associated with risk of POAF. © 2014 Stichting European Society for Clinical Investigation Journal Foundation.

  14. Limiting excessive postoperative blood transfusion after cardiac procedures. A review.

    PubMed Central

    Ferraris, V A; Ferraris, S P

    1995-01-01

    Analysis of blood product use after cardiac operations reveals that a few patients (< or = 20%) consume the majority of blood products (> 80%). The risk factors that predispose a minority of patients to excessive blood use include patient-related factors, transfusion practices, drug-related causes, and procedure-related factors. Multivariate studies suggest that patient age and red blood cell volume are independent patient-related variables that predict excessive blood product transfusion after cardiac procedures. Other factors include preoperative aspirin ingestion, type of operation, over- or underutilization of heparin during cardiopulmonary bypass, failure to correct hypothermia after cardiopulmonary bypass, and physician overtransfusion. A survey of the currently available blood conservation techniques reveals 5 that stand out as reliable methods: 1) high-dose aprotinin therapy, 2) preoperative erythropoietin therapy when time permits adequate dosage before operation, 3) hemodilution by harvest of whole blood immediately before cardiopulmonary bypass, 4) autologous predonation of blood, and 5) salvage of oxygenator blood after cardiopulmonary bypass. Other methods, such as the use of epsilon-aminocaproic acid or desmopressin, cell saving devices, reinfusion of shed mediastinal blood, and hemofiltration have been reported to be less reliable and may even be harmful in some high-risk patients. Consideration of the available data allows formulation of a 4-pronged plan for limiting excessive blood transfusion after surgery: 1) recognize the causes of excessive transfusion, including the importance of red blood cell volume, type of procedure being performed, preoperative aspirin ingestion, etc.; 2) establish a quality management program, including a survey of transfusion practices that emphasizes physician education and availability of real-time laboratory testing to guide transfusion therapy; 3) adopt a multimodal approach using institution-proven techniques; and

  15. [Discontinuous warm cardioplegia in pediatric cardiac surgery: preliminary results].

    PubMed

    Durandy, Y; Hulin, S

    2006-02-01

    This article describes the use of warm cardioplegia in paediatric surgery. Warm blood enriched with potassium was injected every 15 minutes during aortic clamping in 770 operations. The efficacy and quality of this technique were assessed by the return of cardiac electrical activity, troponin I levels 12 hours after aortic clamping and the duration of postoperative ventilation in 3 groups of patients: ventricular septal defect under 6 months (N = 82), tetralogy of Fallot under one year (N = 55), simple transposition of the great arteries (N = 42). These results were compared retrospectively with those obtained using cold cardioplegia. The return of sinus rhythm was spontaneous in 99% of cases versus 77% with cold cardioplegia; the troponin I levels were under 10 ng/ml in 46% of cases versus 37% (NS). Patients operated for ventricular septal defect were ventilated 10 +/- 8 hours versus 13 +/- 10 hours with cold cardioplegia (p = 0.02). The children operated for tetralogy of Fallot were ventilated 8 +/- 4 hours versus 14 +/- 7 hours (p = 0.01) and those with simple transposition 56 +/- 71 hours versus 83 +/- 105 hours (NS). Warm cardioplegia, in the authors' experience, was associated with an improved postoperative course. In this group of 770 operations, 646 operated patients had a stay of less than two days in the intensive care unit.

  16. Outpatient outcomes and satisfaction in pediatric population: data from the postoperative phone call.

    PubMed

    Brenn, B Randall; Choudhry, Dinesh K; Sacks, Karen

    2016-02-01

    Quality and patient/parent satisfaction are goals for pediatric perioperative services. As part of the implementation of our operating room electronic medical record (EMR), a postoperative phone call questionnaire was developed to assess patients discharged after outpatient surgery. The goal of this initiative was to determine the rate of common postoperative complications and understand reasons for patient/parent dissatisfaction. Institutional Review Board approval was obtained for chart review. The postoperative phone call survey was attempted by our postanesthesia care unit nursing staff on all pediatric outpatients. The call was attempted for 3 days. From 2009 to 2013, more than 37 000 phone records existed in our EMR, Epic Optime (Epic Systems, Verona, WI). These data were extracted to a business intelligence (BI) program, QlikView (Qliktech, Radnor, PA, USA). A BI dashboard was constructed to obtain phone call results for any given time frame from monthly to spanning several years. Complications were logged as 4-point severity rating scales (none, mild, moderate, severe) with descriptions for each level. The BI dashboard calculated the overall and rates by severity for the following: (i) nausea, (ii) vomiting, (iii) pain, (iv) bleeding, (v) hoarseness, and (vi) difficulty eating. Of 42 688 outpatient cases, 37 620 postoperative phone calls were completed for an overall response rate of 88%. Pain, at 11.1%, was the highest reported postoperative complication. The rate of dissatisfaction was reported to be 0.31%. Most patients reporting dissatisfaction (62%) did not report any complications. Contingency coefficient showed that there was little relationship between satisfaction and presence of complications. A postoperative phone survey is cost-effective and appreciated by patients. We found that satisfaction with our perioperative services was not related to the rates of reported complications. Although reducing complications is of utmost importance

  17. Pulmonary complications in pediatric cardiac surgery at a university hospital.

    PubMed

    Borges, Daniel Lago; Sousa, Lícia Raquel Teles; Silva, Raquel Teixeira; Gomes, Holga Cristina da Rocha; Ferreira, Fernando Mauro Muniz; Lima, Willy Leite; Borges, Lívia Christina do Prado Lui

    2010-01-01

    To identify the prevalence of pulmonary complications in children undergone cardiac surgery, as well as demographic and clinical characteristics of this population. The sample comprised 37 children of both genders, underwent cardiac surgery at the Hospital Universitário Presidente Dutra, São Luis (MA) during the year of 2007. There were not included patients who had lung disease in pre-operative period, patients with neurological disorders, intra-operative death besides lack of data in medical records. The data were obtained from general medical and nursing staff of their medical records. The population of the study was predominantly composed by female children, from the countryside and at school age. Pathologies considered low risk were the majority, especially the patent ductus arteriosus, interventricular communication and interatrial communication. It was observed that the largest share of children made use of cardiopulmonary bypass for more than 30 minutes, with a median of 80 minutes, suffered a median sternotomy, using only the mediastinal drain and made use of mechanical ventilation after surgery, with the median about 6.6 hours. Only three (8.1%) patients developed pulmonary complications, and of these, two died. Most of the sample was female, school aged and from the countryside. The low time of cardiopulmonary bypass and mechanical ventilation, and congenital heart disease with low risk, may have been factors that contributed to the low rate of pulmonary complications postoperative.

  18. Surgery in Pediatric Crohn's Disease: Indications, Timing and Post-Operative Management

    PubMed Central

    2017-01-01

    Pediatric onset Crohn's disease (CD) tends to have complicated behavior (stricture or penetration) than elderly onset CD at diagnosis. Considering the longer duration of the disease in pediatric patients, the accumulative chance of surgical treatment is higher than in adult onset CD patients. Possible operative indications include perianal CD, intestinal stricture or obstruction, abdominal abscess or fistula, intestinal hemorrhage, neoplastic changes and medically untreatable inflammation. Growth retardation is an operative indication only for pediatric patients. Surgery can affect a patient's clinical course, especially for pediatric CD patient who are growing physically and mentally, so the decision should be made by careful consideration of several factors. The complex and diverse clinical conditions hinder development of a systemized treatment algorithm. Therefore, timing of surgery in pediatric CD patients should be determined with individualized approach by an experienced and well organized multidisciplinary inflammatory bowel disease team. Best long-term outcomes will require proactive post-operative monitoring and therapeutic modifications according to the conditions. PMID:28401051

  19. An audit of post-operative nausea and vomiting, following cardiac surgery: scope of the problem.

    PubMed

    Mace, Lisa

    2003-01-01

    Post-operative nausea and vomiting is a major problem for patients following cardiac surgery. The literature in this area identifies that there are a number of individual patient and post-operative factors which increase the risk of post-operative nausea and vomiting, including female gender, non-smoker, age, use of opioids, pain and anxiety. An audit involving 200 patients, who had undergone cardiac surgery was implemented to assess/evaluate the incidence of nausea and vomiting for this patient group. Data collected included information relating to nausea and vomiting, pain, consumption of morphine and other individual patient variables. The results suggest that nausea and vomiting, is experienced by a large number of patients after cardiac surgery (67%), with the majority suffering on the first day after surgery. The duration of nausea and vomiting for most is short, but for a significant number (7%) it can last up to one-quarter of their initial post-operative course. The paper discusses key implications for practice arising from this project.

  20. Short-duration transcutaneous electrical nerve stimulation in the postoperative period of cardiac surgery.

    PubMed

    Gregorini, Cristie; Cipriano Junior, Gerson; Aquino, Leticia Moraes de; Branco, João Nelson Rodrigues; Bernardelli, Graziella França

    2010-03-01

    Respiratory muscle strength has been related to the postoperative outcome of cardiac surgeries. The main documented therapeutic purpose of transcutaneous electrical nerve stimulation (TENS) is the reduction of pain, which could bring secondary benefits to the respiratory muscles and, consequently, to lung capacities and volumes. The objective of the present study was to evaluate the effectiveness of short-duration transcutaneous electrical nerve stimulation (TENS) in the reduction of pain and its possible influence on respiratory muscle strength and lung capacity and volumes of patients in the postoperative period of cardiac surgery. Twenty five patients with mean age of 59.9 +/- 10.3 years, of whom 72% were men, and homogeneous as regards weight and height, were randomly assigned to two groups. One group received therapeutic TENS (n = 13) and the other, placebo TENS (n = 12), for four hours on the third postoperative day of cardiac surgery. Pain was analyzed by means of a visual analogue scale, and of respiratory muscle strength as measured by maximum respiratory pressures and lung capacity and volumes before and after application of TENS. Short-duration TENS significantly reduced pain of patients in the postoperative period (p < 0.001). Respiratory muscle strength (p < 0.001), tidal volume (p < 0.001) and vital capacity (p < 0.05) significantly improved after therapeutic TENS, unlike in the placebo group. Short-duration TENS proved effective for the reduction of pain and improvement of respiratory muscle strength, as well as of lung volumes and capacity.

  1. Reducing Unnecessary Postoperative Complete Blood Count Testing in the Pediatric Intensive Care Unit

    PubMed Central

    Dewan, Maya; Galvez, Jorge; Polsky, Tracey; Kreher, Genna; Kraus, Blair; Ahumada, Luis; McCloskey, John; Wolfe, Heather

    2017-01-01

    Context: Complete blood count (CBC) testing commonly occurs to determine the need for blood transfusions after surgical procedures. Many clinicians believe postoperative CBCs are “routine.” Objective: To decrease unnecessary routine CBC testing in a low-risk cohort of postoperative patients in the pediatric intensive care unit (PICU) at The Children’s Hospital of Philadelphia by 50% in 6 months. Design: Quality-improvement study. Data from our institution regarding frequency of ordering laboratory studies and transfusion requirements were collected for prior quality-improvement work demonstrating the safety and feasibility of avoiding routine postoperative CBCs in this cohort. Baseline survey data were gathered from key stakeholders on attitudes about and utilization of routine postoperative laboratory testing. Patient and clinician data were shared with all PICU clinicians. Simple Plan-Do-Study-Act cycles involving education, audit, and feedback were put into place. Main Outcome Measures: Percentage of postoperative patients receiving CBCs within 48 hours of PICU admission. Balancing measures were hemoglobin level below 8 g/dL in patients for whom CBCs were sent and blood transfusions up to 7 days postoperatively for any patients in this cohort. Results: Sustained decreases below our 50% goal were seen after our interventions. There were no hemoglobin results below 8 g/dL or surgery-related blood transfusions in this cohort within 7 days of surgery. Estimated hospital charges related to routine postoperative CBCs decreased by 87% during 6 postintervention months. Conclusion: A simple approach to a systemic problem in the PICU of unnecessary laboratory testing is feasible and effective. By using local historical data, we were able to identify a cohort of patients for whom routine postoperative CBC testing is unnecessary. PMID:28241909

  2. Dose optimization in pediatric cardiac x-ray imaging

    SciTech Connect

    Gislason, Amber J.; Davies, Andrew G.; Cowen, Arnold R.

    2010-10-15

    Purpose: The aim of this research was to explore x-ray beam parameters with intent to optimize pediatric x-ray settings in the cardiac catheterization laboratory. This study examined the effects of peak x-ray tube voltage (kVp) and of copper (Cu) x-ray beam filtration independently on the image quality to dose balance for pediatric patient sizes. The impact of antiscatter grid removal on the image quality to dose balance was also investigated. Methods: Image sequences of polymethyl methacrylate phantoms approximating chest sizes typical of pediatric patients were captured using a modern flat-panel receptor based x-ray imaging system. Tin was used to simulate iodine-based contrast medium used in clinical procedures. Measurements of tin detail contrast and flat field image noise provided the contrast to noise ratio. Entrance surface dose (ESD) and effective dose (E) measurements were obtained to calculate the figure of merit (FOM), CNR{sup 2}/dose, which evaluated the dose efficiency of the x-ray parameters investigated. The kVp, tube current (mA), and pulse duration were set manually by overriding the system's automatic dose control mechanisms. Images were captured with 0, 0.1, 0.25, 0.4, and 0.9 mm added Cu filtration, for 50, 55, 60, 65, and 70 kVp with the antiscatter grid in place, and then with it removed. Results: For a given phantom thickness, as the Cu filter thickness was increased, lower kVp was favored. Examining kVp alone, lower values were generally favored, more so for thinner phantoms. Considering ESD, the 8.5 cm phantom had the highest FOM at 50 kVp using 0.4 mm of Cu filtration. The 12 cm phantom had the highest FOM at 55 kVp using 0.9 mm Cu, and the 16 cm phantom had highest FOM at 55 kVp using 0.4 mm Cu. With regard to E, the 8.5 and 12 cm phantoms had the highest FOM at 50 kVp using 0.4 mm of Cu filtration, and the 16 cm phantom had the highest FOM at 50 kVp using 0.25 mm Cu. Antiscatter grid removal improved the FOM for a given set of x

  3. Cardiac surgery patients' evaluation of the quality of theatre nurse postoperative follow-up visit.

    PubMed

    Falk-Brynhildsen, Karin; Nilsson, Ulrica

    2009-06-01

    Theatre nurses at the Department of Cardiothoracic Surgery in Orebro, Sweden, have since 2001 routinely conducted a follow-up visit to postoperative cardiac patients. A model with a standardized information part and an individual-caring conversation including both a retrospective and a prospective part designed the visit. The purpose of this study was to evaluate the quality of the postoperative follow-up visit conducted by the theatre nurses and find out if the quality was related to gender or type of admission. The method was prospective and explorative, including 74 cardiac surgery patients who had had a postoperative follow-up visit by a theatre nurse in Sweden. The instrument measuring quality, from the patient's perspective, measured the quality of the visit, and consisted of 16 items modified to suit the study. The results showed an overall high quality rating, with statistically significant higher scores for six items between patients who had undergone emergency surgery, in comparison with elective patients. When comparing gender, women had statistically significant higher scores in two items. In conclusion, this postoperative follow-up visit by the theatre nurse was a valuable and useful tool especially for the patients who had undergone emergency surgery. In the follow-up visit the theatre nurse creates a caring relationship by meeting the patient as an individual with his/her own experience and needs for information about the surgery, intra and postoperative care, and recovery.

  4. [Evaluation of pain intensity and vital signs in the cardiac surgery postoperative period].

    PubMed

    Miranda, Adriana de Fátima Alencar; da Silva, Lúcia de Fátima; Caetano, Joselany Áfio; de Sousa, Ana Cláudia; Almeida, Paulo César

    2011-04-01

    The objective of this study is to analyze the changes in vital signs of postoperative cardiac surgery patients, according to the referred pain intensity. This descriptive-exploratory study was performed using quantitative analysis to investigate 38 patients submitted to a first dressing change. The analysis of the data, measured before and after performing the nursing procedure, indicated that the manifestation of pain occurred at different levels. The main changes in vital signs referred to blood pressure. In conclusion, there is a relationship between pain intensity and vital signs, and the care that is delivered is indispensible to reestablishing the health state of the postoperative patient.

  5. An initial experience with a digital drainage system during the postoperative period of pediatric thoracic surgery

    PubMed Central

    Costa, Altair da Silva; Bachichi, Thiago; Holanda, Caio; Rizzo, Luiz Augusto Lucas Martins De

    2016-01-01

    ABSTRACT Objective: To report an initial experience with a digital drainage system during the postoperative period of pediatric thoracic surgery. Methods: This was a prospective observational study involving consecutive patients, ≤ 14 years of age, treated at a pediatric thoracic surgery outpatient clinic, for whom pulmonary resection (lobectomy or segmentectomy via muscle-sparing thoracotomy) was indicated. The parameters evaluated were air leak (as quantified with the digital system), biosafety, duration of drainage, length of hospital stay, and complications. The digital system was used in 11 children (mean age, 5.9 ± 3.3 years). The mean length of hospital stay was 4.9 ± 2.6 days, the mean duration of drainage was 2.5 ± 0.7 days, and the mean drainage volume was 270.4 ± 166.7 mL. The mean maximum air leak flow was 92.78 ± 95.83 mL/min (range, 18-338 mL/min). Two patients developed postoperative complications (atelectasis and pneumonia, respectively). The use of this digital system facilitated the decision-making process during the postoperative period, reducing the risk of errors in the interpretation and management of air leaks. PMID:28117476

  6. Tranexamic Acid in cardiac surgery and postoperative seizures: a case report series.

    PubMed

    Bell, David; Marasco, Silvana; Almeida, Aubrey; Rowland, Michael

    2010-08-01

    With the recent withdrawal of the antifibrinolytic aprotinin from the market, tranexamic acid (TxA) has become more widely used. This change has led to increasing concern about the side-effect profile of TxA, particularly the incidence of postoperative seizures. In this case series, we describe 7 patients over an 18-month period who had open-chamber cardiac surgery and developed seizures in the postoperative period. This incidence is increased compared with that of a cohort of patients in the previous 36 months who did not receive TxA (0.66% versus 0%; P < .05). The exact mechanism of TxA-induced seizures is thought to be via inhibition of gamma-aminobutyric acid receptors in neurons. Data from the neurosurgical literature show a well-established link between this antifibrinolytic and seizures. There is now increasing awareness of this association in cardiac surgery, particularly when high TxA doses are used.

  7. [Effectiveness of activated factor VII in postoperative bleeding after cardiac surgery with extracorporeal membrane oxygenation].

    PubMed

    López-Herce Cid, J; Arriola Pereda, G; Zunzunegui Martínez, J L; Brandstrup Azuero, K B

    2005-05-01

    A 4-year-old girl suffered severe postoperative chest tube drainage bleeding after cardiac transplant surgery requiring extracorporeal membrane oxygenation. Transfusions of platelets and fresh frozen plasma failed to decrease the bleeding. At 2.5 hours a dose of 180 mcg/kg of recombinant activated Factor VII was administered. The hemorrhage decreased from 45 ml/kg/h in the first 2.5 hours to 17 ml/kg/h in the next 2.5 hours. The same dose of recombinant activated Factor VII was administered and the hemorrhage suddenly decreased to 1.5 ml/kg/h in the next 2.5 hours, with subsequent disappearance. No adverse events related to activated Factor VII were observed. Recombinant activated Factor VII may be useful in some cases of severe postoperative bleeding in children after cardiac surgery. Randomized controlled studies are needed to confirm its safety and efficacy, and to evaluate the most suitable dose.

  8. Risk factors for the development of postoperative pneumonia after cardiac surgery.

    PubMed

    Vera Urquiza, Rafael; Bucio Reta, Eduardo Rafael; Berríos Bárcenas, Enrique Alexander; Choreño Machain, Tania

    2016-01-01

    Identify risk factors that determine pneumonia development in patients who have undergone cardiac surgery. Prospective study of a single cohort in a postoperative intensive care unit at a tertiary care center, encompassing all patients undergoing cardiac surgery from January to July 2014. 31 postoperative pneumonia cases were enrolled out of 211 patients (14.6%). The following independent risk factors were identified: hypertension (OR: 3.94, p=0.01), chronic renal failure (OR: 13.67, p=0.02), reintubation (OR: 22.29, p=0.001) and extubation after 6h (OR: 15.81, p=0.005). Main determinants for pneumonia after surgery were hypertension, chronic renal failure, extubation after 6h and reintubation. Copyright © 2016. Publicado por Masson Doyma México S.A.

  9. 012. Impact of smoking status on preoperative profile and on postoperative outcome in cardiac surgical patients

    PubMed Central

    Ampatzidou, Fotini; Kontakiotis, Theodoros; Kechagioglou, George; Madesis, Athanasios; Karaiskos, Theodoros; Sileli, Maria; Vlachou, Athanasia; Ignatiadis, Agisilaos; Drossos, George

    2015-01-01

    Objective Aim of our retrospective study is to investigate the impact of smoking status on preoperative profile and on postoperative outcome. Methods A total of 964 patients underwent cardiac surgery procedures from May 2012 to September 2014. Patients were divided in three categories based on their preoperative smoking status: nonsmokers (Group A, n=282), current smokers (Group B, n=15) and ex-smokers (Group C, n=667). The following preoperative patients’ characteristics were recorded: age, body mass index (BMI), obstructive pulmonary disease (COPD), Euroscore II (predictive score), diabetes mellitus and ejection fraction (EF). Postoperative adverse events and mortality were also recorded: use of intra-aortic balloon pump (IABP), low cardiac output syndrome, atrial fibrillation, acute kidney injury, re-intubation, acute respiratory failure managed by noninvasive ventilation, pneumonia, prolonged mechanical ventilation (>48 hours), stroke and death. Statistical analysis based on one way analysis of variance (ANOVA) method while differences between groups were analyzed by the post hoc test. COPD and non-COPD percentages were analyzed by the χ2 test. Results No statistical significant correlation in postoperative adverse events and mortality was found between the groups. The only exception was the use of IABP which was more common in patients with a history of smoking (P<0.05). Statistical significant correlation was revealed in the following preoperative patients’ profile characteristics: age (P<0.01), COPD (P=0.011) and EF (P=0.011). Conclusions According to our findings, preoperative smoking status has no impact on postoperative outcome in cardiac surgery patients. Patients with a history of smoking who underwent cardiac surgery procedures are younger, have lower ejection fraction and COPD is more common.

  10. Invasive aspergillosis associated with systemic lupus erythematosus and cardiac postoperative complication

    PubMed Central

    Macêdo, Danielle Patrícia Cerqueira; Silva-Júnior, Heraldo Maia; de Souza-Motta, Cristina Maria; Milan, Eveline Pípolo; Neves, Rejane Pereira

    2009-01-01

    Aspergillus is a ubiquitous fungus which can cause a variety of clinical syndromes. This fungus has emerged as agent of systemic infections and has therefore gained considerable public health importance. This paper describes two cases of invasive aspergillosis caused by A. fumigatus in immuno-suppressed patients and underscores the importance of early identification of Aspergillus infection associated with systemic lupus erythematosus and cardiac postoperative complications. PMID:24031340

  11. Transversus abdominis plane catheters for postoperative pain relief in pediatric patients

    PubMed Central

    Bakshi, Sumitra G.; Doctor, Jeson R.; Trivedi, Bhakti D.; Qureshi, Sajid S.

    2017-01-01

    Regional techniques provides excellent post operative pain relief in pediatric patients. Transversus abdominis plane (TAP) block is a newer regional technique available. Though there is emerging evidence proving the efficacy of TAP blocks, there is limited literature on use of TAP catheters in pediatric patients. TAP catheters were placed in two children following laparotomy with transverse incisions and in both epidural was avoided, with good post operative pain relief. Ultrasound guidance was used in one child, while in the other the catheter was placed under direct vision after dissection of the plane between transversus abdominis and internal oblique. Intermittent boluses of high volumes of local anesthetic (0.6-0.7 ml/kg) were used through the TAP catheter, ensuring that the maximum permissible level of bupivacaine was not exceeded. In adults, continuous abdominal catheters have found a place for post-operative pain management, when epidural analgesia is contraindicated. At present, the use of TAP catheters by pediatric anesthesiologists is limited, though there exists diverse clinical scenarios when these catheters may be of benefit. Contraindication of neuraxial blockade and septic patients are the two scenarios we have reported. In conclusion, TAP catheters are effective analgesia technique for laparotomies with transverse incision in pediatric patients. PMID:28413286

  12. Incidence, presentation and risk factors of late postoperative pericardial effusions requiring invasive treatment after cardiac surgery.

    PubMed

    Khan, Niina K; Järvelä, Kati M; Loisa, Eetu L; Sutinen, Jaakko A; Laurikka, Jari O; Khan, Jahangir A

    2017-06-01

    Occurrence and risk factors of late postoperative pericardial effusions requiring invasive treatment, i.e. pretamponade and tamponade, following cardiac surgery are incompletely described in current literature. The purpose of this study was to define the incidence and presentation of late pretamponade and tamponade as well as to outline significant predisposing factors. A cohort of 1356 consecutive cardiac surgery patients treated in a tertiary academic centre between January 2013 and December 2014 was followed up for 6 months after surgery. Pericardial effusion was considered late when presenting after the 7th postoperative day. The incidence, timing and risk factors, as well as symptoms and clinical findings associated with late pretamponade and tamponade in patients surviving at least 7 days was analysed. Of 1308 patients included in the analysis, 81 (6.2%) underwent invasive treatment for late postoperative pericardial effusion, 27 (2.1%) for pretamponade and 54 (4.1%) for tamponade, respectively, with a median delay of 11 (range 8-87) days after the primary operation. Haemodynamic instability was present in 34.6%, signs of cardiac chamber compression in 54.3% and subjective symptoms, mostly dyspnoea, in 56.8% of patients, respectively. Treated patients were younger, had lower EuroSCORE-II rating, less coronary disease, better cardiac function, higher preoperative haemoglobin values and had mostly undergone elective surgery involving cardiac valves. In multivariable analysis, independent risk factors were single valve surgery and high preoperative haemoglobin level, whereas age 60-69 years was associated with lower risk. Younger, generally healthier patients undergoing valve surgery are at greatest risk for developing late tamponade or pretamponade.

  13. Preoperative Nutritional Status and Clinical Complications in the Postoperative Period of Cardiac Surgeries

    PubMed Central

    Gonçalves, Luciana de Brito; de Jesus, Natanael Moura Teixeira; Gonçalves, Maiara de Brito; Dias, Lidiane Cristina Gomes; Deiró, Tereza Cristina Bomfim de Jesus

    2016-01-01

    Objective This study aims to assess the preoperative nutritional status of patients and the role it plays in the occurrence of clinical complications in the postoperative period of major elective cardiac surgeries. Methods Cross-sectional study comprising 72 patients aged 20 years or older, who underwent elective cardiac surgery. The preoperative nutritional assessment consisted of nutritional screening, anthropometry (including the measurement of the adductor pollicis muscle thickness) and biochemical tests. The patients were monitored for up to 10 days after the surgery in order to control the occurrence of postoperative complications. The R software, version 3.0.2, was used to statistically analyze the data. Results Clinical complications were found in 62.5% (n=42) of the studied samples and complications of non-infectious nature were most often found. Serum albumin appeared to be associated with renal complications (P=0.026) in the nutritional status indicators analyzed herein. The adductor pollicis muscle thickness was associated with infectious complications and presented mean of 9.39±2.32 mm in the non-dominant hand (P=0.030). No significant correlation was found between the other indicators and the clinical complications. Conclusion The adductor pollicis muscle thickness and the serum albumin seemed be associated with clinical complications in the postoperative period of cardiac surgeries. PMID:27982346

  14. Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.

    PubMed

    Bowermaster, Rebecca; Miller, Megan; Ashcraft, Traci; Boyd, Michael; Brar, Anoop; Manning, Peter; Eghtesady, Pirooz

    2015-02-01

    Cardiac surgical procedures are complex and require the coordinated action of many. This creates the potential for small failures that could be the substrate for subsequent morbidity or mortality. High-reliability science suggests that preoccupation with small failures can lead to improved outcomes. Failures of all magnitudes (ie, events) were captured within the pediatric cardiac operating room starting with a single surgeon in April 2008. As the surgical team became more familiar with the process, failure recording was extended to all surgeons and all surgical procedures performed until the conclusion of the study in December 2010. New recording processes were developed and used on a rolling basis during this study. With systematic capture, event rates increased (from occurring within 20% to 50% of operative procedures). Although we identified 9 recurrent patterns, 2 categories (ie, Equipment and Patient Instability) accounted for almost half of the events (45%). The greatest number of events occurred during the prebypass period (40.2%), compared with bypass (20.1%) and postbypass (32.3%) periods. These events were mainly difficulties in access (31.8%), equipment (42.4%), and patient instability (33.3%) in each of the epochs, respectively. Of all events, 7.3% occurred during nonbypass cases, 30.6% of these were communication events. Implementation of this initiative led to recognition of major system-wide issues (eg, need for change in the blood-product acquisition process). Preoccupation with all failures in the operating room can reveal important information about the operating room and perioperative microenvironment that can prompt substantive process changes both locally and within the larger health system. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

  15. Milrinone Use is Associated With Postoperative Atrial Fibrillation Following Cardiac Surgery

    PubMed Central

    Fleming, Gregory A.; Murray, Katherine T.; Yu, Chang; Byrne, John G.; Greelish, James P.; Petracek, Michael R.; Hoff, Steven J.; Ball, Stephen K.; Brown, Nancy J.; Pretorius, Mias

    2009-01-01

    Background Postoperative atrial fibrillation (AF), a frequent complication following cardiac surgery, causes morbidity and prolongs hospitalization. Inotropic drugs are commonly used perioperatively to support ventricular function. This study tested the hypothesis that the use of inotropic drugs is associated with postoperative AF. Methods and Results We evaluated perioperative risk factors in 232 patients who underwent elective cardiac surgery. All patients were in sinus rhythm at surgery. Sixty-seven (28.9%) patients developed AF a mean of 2.9±2.1 days after surgery. Patients who developed AF stayed in the hospital longer (P<0.001) and were more likely to die (P=0.02). Milrinone use was associated with an increased risk of postoperative AF (58.2% versus 26.1% in non-users, P<0.001). Older age (63.4±10.7 versus 56.7±12.3 years, P<0.001), hypertension (P=0.04), lower preoperative ejection fraction (P=0.03), mitral valve surgery (P=0.02), right ventricular dysfunction (P=0.03), and higher mean pulmonary artery pressure (PAP) (27.1±9.3 versus 21.8±7.5 mmHg, P=0.001) were also associated with postoperative AF. In multivariable logistic regression, age (P<0.001), ejection fraction (P=0.02), and milrinone use (odds ratio 4.86, 95% CI 2.31-10.25, P<0.001) independently predicted postoperative AF. When data only from patients with pulmonary artery catheters were analyzed and PAP was included in the model, age, milrinone use (odds ratio 4.45, 95% CI 2.01-9.84, P<0.001), and higher PAP (P=0.02) were associated with an increased risk of postoperative AF. Adding other potential confounders or stratifying analysis by mitral valve surgery did not change the association of milrinone use with postoperative AF. Conclusion Milrinone use is an independent risk factor for postoperative AF following elective cardiac surgery. PMID:18824641

  16. [Managing postoperative pain in pediatric nursing: searching for subsides to improve nursing care].

    PubMed

    Queiroz, Fernanda Cristina; Nascimento, Lucila Castanheira; Leite, Adriana Moraes; Flória-Santos, Milena; de Lima, Regina Aparecida Garcia; Scochi, Carmen Gracinda Silvan

    2007-01-01

    This study reports on a literature review about child postoperative pain management by nursing professionals, in the period from 1993 to 2005. Three themes were identified: factors influencing nurses' management of child pain, interventions to relieve child pain, and nurses' assessment and response to children's pain experience. Child pain management is a complex act that involves elements of the dimensions related to the children themselves, health professionals and family members. The lack of studies in this area reveals the need for research, with a view to (re)considering pediatric nursing care.

  17. Postoperative Arrhythmias after Cardiac Surgery: Incidence, Risk Factors, and Therapeutic Management

    PubMed Central

    Cianflone, Domenico

    2014-01-01

    Arrhythmias are a known complication after cardiac surgery and represent a major cause of morbidity, increased length of hospital stay, and economic costs. However, little is known about incidence, risk factors, and treatment of early postoperative arrhythmias. Both tachyarrhythmias and bradyarrhythmias can present in the postoperative period. In this setting, atrial fibrillation is the most common heart rhythm disorder. Postoperative atrial fibrillation is often self-limiting, but it may require anticoagulation therapy and either a rate or rhythm control strategy. However, ventricular arrhythmias and conduction disturbances can also occur. Sustained ventricular arrhythmias in the recovery period after cardiac surgery may warrant acute treatment and long-term preventive strategy in the absence of reversible causes. Transient bradyarrhythmias may be managed with temporary pacing wires placed at surgery, but significant and persistent atrioventricular block or sinus node dysfunction can occur with the need for permanent pacing. We provide a complete and updated review about mechanisms, risk factors, and treatment strategies for the main postoperative arrhythmias. PMID:24511410

  18. Recombinant factor VIIa in the treatment of postoperative hemorrhage after cardiac surgery.

    PubMed

    Raivio, Peter; Suojaranta-Ylinen, Raili; Kuitunen, Anne H

    2005-07-01

    A generalized coagulation disorder after cardiac surgery that is associated with massive postoperative hemorrhage is not completely understood. Recombinant factor VIIa (rFVIIa) has emerged as a possible "salvage" medication. Limited experience reported in the literature and fears of possible thromboembolic complications make the use of rFVIIa in the treatment of bleeding after cardiac surgery controversial. We analyzed retrospectively all consecutive cardiac surgical patients who have received rFVIIa in the Helsinki University Hospital in order to evaluate the safety and efficacy of rFVIIa after cardiac surgery in our institution. Altogether, 16 patients were identified from operating room and intensive care unit (ICU) databases. Patient records and operating room and ICU databases were reviewed. In this series of high risk patients hospital mortality was high (25%). A definite hemostatic effect was seen after rFVIIa administration in all but three patients (82%). Mean amount of bleeding and amount of platelet and fresh frozen plasma transfusions decreased significantly after rFVIIa administration. Four patients had serious postoperative thromboembolic complications. Recombinant factor VIIa was effective in restoring hemostasis, but thromboembolic complications occurred after rFVIIa use. They may be related to the underlying pathologies and surgery performed. It is possible, however, that rFVIIa treatment contributed to their occurrence.

  19. Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Fluid Management.

    PubMed

    McCammond, Amy N; Axelrod, David M; Bailly, David K; Ramsey, E Zachary; Costello, John M

    2016-03-01

    In this Consensus Statement, we review the etiology and pathophysiology of fluid disturbances in critically ill children with cardiac disease. Clinical tools used to recognize pathologic fluid states are summarized, as are the mechanisms of action of many drugs aimed at optimal fluid management. The expertise of the authors and a review of the medical literature were used as data sources. The authors synthesized the data in the literature in order to present clinical tools used to recognize pathologic fluid states. For each drug, the physiologic rationale, mechanism of action, and pharmacokinetics are synthesized, and the evidence in the literature to support the therapy is discussed. Fluid management is challenging in critically ill pediatric cardiac patients. A myriad of causes may be contributory, including intrinsic myocardial dysfunction with its associated neuroendocrine response, renal dysfunction with oliguria, and systemic inflammation with resulting endothelial dysfunction. The development of fluid overload has been associated with adverse outcomes, including acute kidney injury, prolonged mechanical ventilation, increased vasoactive support, prolonged hospital length of stay, and mortality. An in-depth understanding of the many factors that influence volume status is necessary to guide optimal management.

  20. Acute Decompensation in Pediatric Cardiac Patients: Outcomes After Rapid Response Events.

    PubMed

    Bavare, Aarti C; Rafie, Kimia S; Bastero, Patricia X; Hagan, Joseph L; Checchia, Paul A

    2017-05-01

    We studied rapid response events after acute clinical instability outside ICU settings in pediatric cardiac patients. Our objective was to describe the characteristics and outcomes after rapid response events in this high-risk cohort and elucidate the cardiac conditions and risk factors associated with worse outcomes. A retrospective single-center study was carried out over a 3-year period from July 2011 to June 2014. Referral high-volume pediatric cardiac center located within a tertiary academic pediatric hospital. All rapid response events that occurred during the study period were reviewed to identify rapid response events in cardiac patients. None. We reviewed 1,906 rapid response events to identify 152 rapid response events that occurred in 127 pediatric cardiac patients. Congenital heart disease was the baseline diagnosis in 74% events (single ventricle, 28%; biventricle physiology, 46%). Seventy-four percent had a cardiac surgery before rapid response, 37% had ICU stay within previous 7 days, and acute kidney injury was noted in 41% post rapid response. Cardiac and/or pulmonary arrest occurred during rapid response in 8.5%. Overall, 81% were transferred to ICU, 22% had critical deterioration (ventilation or vasopressors within 12 hr of transfer), and 56% received such support and/or invasive procedures within 72 hours. Mortality within 30 days post event was 14%. Significant outcome associations included: single ventricle physiology-increased need for invasive procedures and mortality (adjusted odds ratio, 2.58; p = 0.02); multiple rapid response triggers-increased ICU transfer and interventions at 72 hours; critical deterioration-cardiopulmonary arrest and mortality; and acute kidney injury-cardiopulmonary arrest and need for hemodynamic support. Congenital heart disease, previous cardiac surgery, and recent discharge from ICU were common among pediatric cardiac rapid responses. Progression to cardiopulmonary arrest during rapid response, need for ICU

  1. The Association of Brain MRI Characteristics and Postoperative Delirium in Cardiac Surgery Patients

    PubMed Central

    Brown, Charles; Faigle, Roland; Klinker, Lauren; Bahouth, Mona; Max, Laura; LaFlam, Andrew; Neufeld, Karin J.; Mandal, Kaushik; Gottesman, Rebecca; Hogue, Charles

    2016-01-01

    Purpose Delirium is common after cardiac surgery, and it is associated with short- and long-term consequences, including cognitive decline. Identification of patients who are vulnerable to delirium might allow for early implementation of delirium-prevention strategies in older adults undergoing surgery. Brain MRI findings provide insight into structural brain changes that may identify vulnerable patients. The purpose of this study was to examine the association between brain MRI characteristics potentially associated with delirium vulnerability and the development of postoperative delirium in a nested cohort of patients undergoing cardiac surgery. Methods We identified 79 cardiac surgery patients who had brain MRI imaging after cardiac surgery, as part of an ongoing randomized trial evaluating the efficacy of blood pressure management based on cerebral autoregulation monitoring versus standard management for improving neurological outcomes. Cerebral lateral ventricular size, cortical sulcal width, and white matter hyperintensities (WMH) on brain MRI scans were graded on a validated 0 to 9 scale, and categorized into tertiles. New ischemic lesions were characterized as present or absent. Delirium was assessed using a validated chart-review. Neuropsychological testing performed before surgery was used to establish preoperative cognitive baseline. Multivariable logistic regression was used to assess the independent association between MRI characteristics and postoperative delirium. Findings Twenty-eight of 79 (35.4%) patients developed postoperative delirium. Patients with delirium had higher unadjusted ventricular size (median 4 vs. 3, p=0.003), and there was a trend towards higher sulcal sizes and WMH grades. Increasing tertiles of ventricular size (Odds Ratio [OR] 3.59; 95% Confidence Interval [CI] 1.59–8.12; p=0.002) and sulcal size (OR 2.15; 95%CI 1.13–4.12; p=0.02) were associated with postoperative delirium, with a trend for tertiles of WMH grade (OR 1

  2. The use of the virtual reality as intervention tool in the postoperative of cardiac surgery.

    PubMed

    Cacau, Lucas de Assis Pereira; Oliveira, Géssica Uruga; Maynard, Luana Godinho; Araújo Filho, Amaro Afrânio de; Silva, Walderi Monteiro da; Cerqueria Neto, Manoel Luiz; Antoniolli, Angelo Roberto; Santana-Filho, Valter J

    2013-06-01

    Cardiac surgery has been the intervention of choice in many cases of cardiovascular diseases. Susceptibility to postoperative complications, cardiac rehabilitation is indicated. Therapeutic resources, such as virtual reality has been helping the rehabilitational process. The aim of the study was to evaluate the use of virtual reality in the functional rehabilitation of patients in the postoperative period. Patients were randomized into two groups, Virtual Reality (VRG, n = 30) and Control (CG, n = 30). The response to treatment was assessed through the functional independence measure (FIM), by the 6-minute walk test (6MWT) and the Nottingham Health Profile (NHP). Evaluations were performed preoperatively and postoperatively. On the first day after surgery, patients in both groups showed decreased functional performance. However, the VRG showed lower reduction (45.712.3) when compared to CG (35.0612.09, P<0.05) in first postoperative day, and no significant difference in performance on discharge day (P>0.05). In evaluating the NHP field, we observed a significant decrease in pain score at third assessment (P<0.05). These patients also had a higher energy level in the first evaluation (P<0.05). There were no differences with statistical significance for emotional reactions, physical ability, and social interaction. The length of stay was significantly shorter in patients of VRG (9.410.5 days vs. 12.2 1 0.9 days, P<0.05), which also had a higher 6MWD (319.9119.3 meters vs. 263.5115.4 meters, P<0.02). Adjunctive treatment with virtual reality demonstrated benefits, with better functional performance in patients undergoing cardiac surgery.

  3. Melatonin treatment in the prevention of postoperative delirium in cardiac surgery patients

    PubMed Central

    Artemiou, Panagiotis; Bilecova-Rabajdova, Miroslava; Sabol, Frantisek; Torok, Pavol; Kolarcik, Peter; Kolesar, Adrian

    2015-01-01

    Introduction Post-cardiac surgery delirium is a severe complication. The circadian rhythm of melatonin secretion has been shown to be altered postoperatively. Aim of the study It was hypothesized that restoring normal sleeping patterns with a substance that is capable of resynchronizing circadian rhythm such as exogenous administration of melatonin may possibly reduce the incidence of postoperative delirium. Material and methods This paper represents a prospective clinical observational study. Two consecutive groups of 250 consecutive patients took part in the study. Group A was the control group and group B was the melatonin group. In group B, the patients received prophylactic melatonin treatment. The main objectives were to observe the incidence of delirium, to identify any predictors of delirium, and to compare the two groups based on the delirium incidence. Results The incidence of delirium was 8.4% in the melatonin group vs. 20.8% in the control group (p = 0.001). Predictors of delirium in the melatonin group were age (p = 0.001) and higher EuroSCORE II value (p = 0.001). In multivariate analysis, age and EuroSCORE II value (p = 0.014) were predictors of postoperative delirium. Comparing the groups, the main predictors of delirium were age (p = 0.001), EuroSCORE II value (p = 0.001), cardio-pulmonary bypass (CPB) time (p = 0.001), aortic cross-clamping (ACC) time (p = 0.008), sufentanil dose (p = 0.001) and mechanical ventilation (p = 0.033). Conclusions Administration of melatonin significantly decreases the incidence of postoperative delirium after cardiac surgery. Prophylactic treatment with melatonin should be considered in every patient scheduled for cardiac surgery. PMID:26336494

  4. Postoperative vomiting in pediatric oncologic patients: prediction by a fuzzy logic model.

    PubMed

    Bassanezi, Betina S B; de Oliveira-Filho, Antônio G; Jafelice, Rosana S M; Bustorff-Silva, Joaquim M; Udelsmann, Artur

    2013-01-01

    To report a fuzzy logic mathematical model to predict postoperative vomiting (POV) in pediatric oncologic patients and compare with preexisting scores. Although POV has a high incidence in children and may decrease parental satisfaction after surgeries, there is only one specific score that predicts POV in children: the Eberhart's score. In this study, we report a fuzzy model that intends to predict the probability of POV in pediatric oncologic patients. Fuzzy logic is a mathematical theory that recognizes more than simple true and false values and takes into account levels of continuous variables such as age or duration of the surgery. The fuzzy model tries to account for subjectiveness in the variables. Preoperative potential risk factors for POV in 198 children (0-19 year old) with malignancies were collected and analyzed. Data analysis was performed with the chi-square test and logistic regression to evaluate probable risk factors for POV. A system based on fuzzy logic was developed with the risk factors found in the logistic regression, and a computational interface was created to calculate the probability of POV. The model showed a good performance in predicting POV. After the analysis, the model was compared with Eberhart's score in the same population and showed a better performance. The fuzzy score can predict the chance of POV in children with cancer with good accuracy, allowing better planning for postoperative prophylaxis of vomiting. The computational interface is available for free download at the internet and is very easy to use. © 2012 Blackwell Publishing Ltd.

  5. Heparin-coated bypass circuits: effects on inflammatory response in pediatric cardiac operations.

    PubMed

    Schreurs, H H; Wijers, M J; Gu, Y J; van Oeveren, W; van Domburg, R T; de Boer, J H; Bogers, A J

    1998-07-01

    This study was designed to investigate whether clinical signs of the inflammatory response in pediatric cardiac patients are reduced by heparin-coated cardiopulmonary bypass circuits and how this could be explained by differences in the pathophysiologic mechanisms involved. In a randomized, prospective study 19 patients underwent cardiopulmonary bypass either with Carmeda BioActive Surface bypass circuits (n = 9) or with identical noncoated circuits (control, n = 10). Clinical parameters were recorded during the first 48 hours after the start of operation. Blood samples for determination of terminal complement complex, soluble form of E-selectin, and beta-thromboglobulin were obtained perioperatively up to 24 hours after operation. All clinical and inflammatory mediators showed a tendency in favor of the group with heparin-coated circuits. When analyzed on a point-by-point basis there were significant differences in postoperative central body temperature, soluble E-selectin levels, and beta-thromboglobulin levels (all p < 0.05). These data suggest that the use of heparin-coated cardiopulmonary bypass offers clinical benefit and tends to reduce the release of inflammatory mediators.

  6. Correlation between intraoperative ultrasound and postoperative MRI in pediatric tumor surgery.

    PubMed

    Smith, Heather; Taplin, AmiLyn; Syed, Sohail; Adamo, Matthew A

    2016-11-01

    OBJECTIVE Malignant disease of the CNS is the primary etiology for deaths resulting from cancer in the pediatric population. It has been well documented that outcomes of pediatric neurosurgery rely on the extent of tumor resection. Therefore, techniques that improve surgical results have significant clinical implications. Intraoperative ultrasound (IOUS) offers real-time surgical guidance and a more accurate means for detecting residual tumor that is inconspicuous to the naked eye. The objective of this study was to evaluate the correlation of extent of resection between IOUS and postoperative MRI. The authors measured the correlation of extent of resection, negative predictive value, and sensitivity of IOUS and compared them with those of MRI. METHODS This study consisted of a retrospective review of the medical charts of all pediatric patients who underwent neurosurgical treatment of a tumor between August 2009 and July 2015 at Albany Medical Center. Included were patients who were aged ≤ 21 years, who underwent brain or spinal tumor resection, for whom IOUS was used during the tumor resection, and for whom postoperative MRI (with and without contrast) was performed within 1 week of surgery. RESULTS Sixty-two patients met inclusion criteria for the study (33 males, mean age 10.0 years). The IOUS results very significantly correlated with postoperative MRI results (φ = 0.726; p = 0.000000011; negative predictive value 86.3% [95% CI 73.7%-94.3%]). These results exemplify a 71% overall gross-total resection rate and 80% intended gross-total resection rate with the use of IOUS (i.e., excluding cases performed only for debulking purposes). CONCLUSIONS The use of IOUS may play an important role in achieving a greater extent of resection by providing real-time information on tumor volume and location in the setting of brain shift throughout the course of an operation. The authors support the use of IOUS in pediatric CNS tumor surgery to improve clinical outcomes at

  7. Abnormal Myocardial Contractility After Pediatric Heart Transplantation by Cardiac MRI.

    PubMed

    Grotenhuis, Heynric B; Nyns, Emile C A; Kantor, Paul F; Dipchand, Anne I; Greenway, Steven C; Yoo, Shi-Joon; Tomlinson, George; Chaturvedi, Rajiv R; Grosse-Wortmann, Lars

    2017-08-01

    Acute cellular rejection (ACR) compromises graft function after heart transplantation (HTX). The purpose of this study was to describe systolic myocardial deformation in pediatric HTX and to determine whether it is impaired during ACR. Eighteen combined cardiac magnetic resonance imaging (CMR)/endomyocardial biopsy (EMBx) examinations were performed in 14 HTX patients (11 male, age 13.9 ± 4.7 years; 1.2 ± 1.3 years after HTX). Biventricular function and left ventricular (LV) circumferential strain, rotation, and torsion by myocardial tagging CMR were compared to 11 controls as well as between patients with and without clinically significant ACR. HTX patients showed mildly reduced biventricular systolic function when compared to controls [LV ejection fraction (EF): 55 ± 8% vs. 61 ± 3, p = 0.02; right ventricular (RV) EF: 48 ± 7% vs. 53 ± 6, p = 0.04]. Indexed LV mass was mildly increased in HTX patients (67 ± 14 g/m(2) vs. 55 ± 13, p = 0.03). LV myocardial deformation indices were all significantly reduced, expressed by global circumferential strain (-13.5 ± 2.3% vs. -19.1 ± 1.1%, p < 0.01), basal strain (-13.7 ± 3.0% vs. -17.5 ± 2.4%, p < 0.01), mid-ventricular strain (-13.4 ± 2.7% vs. -19.3 ± 2.2%, p < 0.01), apical strain (-13.5 ± 2.8% vs. -19.9 ± 2.0%, p < 0.01), basal rotation (-2.0 ± 2.1° vs. -5.0 ± 2.0°, p < 0.01), and torsion (6.1 ± 1.7° vs. 7.8 ± 1.1°, p < 0.01). EMBx demonstrated ACR grade 0 R in 3 HTX cases, ACR grade 1 R in 11 HTX cases and ACR grade 2 R in 4 HTX cases. When comparing clinically non-significant ACR (grades 0-1 R vs. ACR 2 R), basal rotation, and apical rotation were worse in ACR 2 R patients (-1.4 ± 1.8° vs. -4.2 ± 1.4°, p = 0.01 and 10.2 ± 2.9° vs. 2.8 ± 1.9°, p < 0.01, respectively). Pediatric HTX recipients demonstrate reduced biventricular systolic function and decreased myocardial contractility. Myocardial deformation indices by

  8. Asian consortium on radiation dose of pediatric cardiac CT (ASCI-REDCARD).

    PubMed

    Hui, Peter K T; Goo, Hyun Woo; Du, Jing; Ip, Janice J K; Kanzaki, Suzu; Kim, Young Jin; Kritsaneepaiboon, Supika; Lilyasari, Oktavia; Siripornpitak, Suvipaporn

    2017-07-01

    With incremental utilization of pediatric cardiac CT in congenital heart disease, it is imperative to define its current radiation dose levels in clinical practice in order to help imagers optimize CT protocols, particularly in Asia and other developing countries where CT physicists are not readily available. To evaluate current radiation dose levels and influencing factors in cardiac CT in children with congenital heart disease in Asia by conducting a retrospective multi-center, multi-vendor study. We included 1,043 pediatric cardiac CT examinations performed in 8 centers between January 2014 and December 2014 to evaluate congenital heart disease. In five weight groups, we calculated radiation dose metrics including volume CT dose index, size-specific dose estimate, dose-length product and effective dose. Age at CT exam, gender, tube voltage, scan mode, CT indication and image reconstruction algorithm were analyzed to learn whether they influenced CT radiation dose. Volume CT dose index, size-specific dose estimate, dose-length product and effective dose of pediatric cardiac CT showed variations in the range of 4.3-23.8 mGy, 4.9-17.6 mGy, 55.8-501.3 mGy∙cm and 1.5-3.2 mSv, respectively, within five weight groups. Gender, tube voltage, scan mode and cardiac function assessment significantly influenced CT radiation dose. This multi-center, multi-vendor study demonstrated variations in radiation dose metrics of pediatric cardiac CT reflecting current practice in Asia. Gender, tube voltage, scan mode and cardiac function assessment should be considered as essential radiation dose-influencing factors in developing optimal pediatric cardiac CT protocols.

  9. Pediatric postoperative intussusception in the minimally invasive surgery era: a 13-year, single center experience.

    PubMed

    Klein, Justin D; Turner, Christopher G; Kamran, Sophia C; Yu, Alvin Y C; Ferrari, Lynne; Zurakowski, David; Fauza, Dario O

    2013-06-01

    Postoperative intussusception (POI) is a sporadic complication whose mechanisms and risk factors remain poorly understood. Its epidemiology in the minimally invasive surgery era has yet to be well described, particularly in children. We sought to examine risk factors, demographics, and anatomic patterns of pediatric POI in recent years. This was a 13-year retrospective review from a single tertiary pediatric center. Variables analyzed included patient demographics, time of occurrence, type of intussusception, type of anesthesia, and triggering surgical procedure. The latter variable was divided into 2 groups: abdominal and nonabdominal interventions. Statistical analysis was by 2-tailed Fisher's exact test with significance set at p < 0.05. Among 822 cases of intussusception in 718 patients, 22 documented cases of POI were identified. Twelve of them occurred after abdominal procedures; there was a statistically significant difference in the incidence of POI after open surgery (0.091%; 11 of 12,126) when compared with minimally invasive interventions (0.013%; 1 of 7,610; p = 0.036). As expected, ileoileal and jejunojejunal intussusceptions were the most common forms of POI after abdominal operations (12 of 12; 100%); however, ileocolic intussusceptions were common forms of POI after nonabdominal cases (5 of 10; 50%; p = 0.01). Epidural anesthesia did not appear to be a risk factor for POI. Although rare, postoperative intussusception can occur after a multitude of interventions, including those performed at a distance from the abdomen. Although small bowel intussusception is the predominant variant of this complication after abdominal procedures, ileocolic intussusception is prevalent after other interventions. Minimally invasive abdominal access may protect against postoperative intussusception in children. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

  10. Evidence-based use of FFP: the influence of a priming strategy without FFP during CPB on postoperative coagulation and recovery in pediatric patients.

    PubMed

    Miao, X; Liu, J; Zhao, M; Cui, Y; Feng, Z; Zhao, J; Long, C; Li, S; Yan, F; Wang, X; Hu, S

    2015-03-01

    Although fresh frozen plasma (FFP) is one of the most commonly used hemostatic agents in clinical specialties today, there is little evidence available supporting its administration. Our present study observed the effects of a priming strategy without FFP during cardiopulmonary bypass (CPB) on postoperative coagulation and clinical recovery in pediatric patients, aiming to supply new evidence for evidence-based use of FFP. Eighty pediatric patients with congenital heart disease undergoing cardiac surgery with CPB were randomized to receive either 10-20 ml/kg 4% succinylated gelatin (Gelofusine, GEL group, n = 40) or 1-2 units FFP (FFP group, n = 40) in the pump prime. Rapid-thromboelastography (r-TEG) and functional fibrinogen level were measured before skin incision and 15 minutes after heparin reversal. We recorded the volume of chest tube drainage, transfusion requirements and the dosage of pharmacological agents. The ventilation time, ICU length of stay and hospitalization time after surgery were also collected. After heparin neutralization, there were significantly elevated levels of fibrinogen in the FFP group, which were manifested by r-TEG parameters MAf and FLEV. No significant differences were observed between the two groups in postoperative bleeding, transfusion requirements and the usage of pharmacological agents. Recovery time was also comparable between the two groups. In conclusion, prophylactic use of FFP in the priming solution does not provide clinical benefits as presumed. Artificial colloids, such as Gelofusine, can be used safely and effectively as a substitute for FFP in the pump prime. TEG is an effective assessment tool to evaluate postoperative coagulation function in pediatric patients. © The Author(s) 2014.

  11. Apoptosis of circulating lymphocytes during pediatric cardiac surgery

    NASA Astrophysics Data System (ADS)

    Bocsi, J.; Pipek, M.; Hambsch, J.; Schneider, P.; Tárnok, A.

    2006-02-01

    There is a constant need for clinical diagnostic systems that enable to predict disease course for preventative medicine. Apoptosis, programmed cell death, is the end point of the cell's response to different induction and leads to changes in the cell morphology that can be rapidly detected by optical systems. We tested whether apoptosis of T-cells in the peripheral blood is useful as predictor and compared different preparation and analytical techniques. Surgical trauma is associated with elevated apoptosis of circulating leukocytes. Increased apoptosis leads to partial removal of immune competent cells and could therefore in part be responsible for reduced immune defence. Cardiovascular surgery with but not without cardiopulmonary bypass (CPB) induces transient immunosuppression. Its effect on T-cell apoptosis has not been shown yet. Flow-cytometric data of blood samples from 107 children (age 3-16 yr.) who underwent cardiac surgery with (78) or without (29) CPB were analysed. Apoptotic T-lymphocytes were detected based on light scatter and surface antigen (CD45/CD3) expression (ClinExpImmunol2000;120:454). Results were compared to staining with CD3 antibodies alone and in the absence of antibodies. T-cell apoptosis rate was comparable when detected with CD45/CD3 or CD3 alone, however not in the absence of CD3. Patients with but not without CPB surgery had elevated lymphocyte apoptosis. T-cell apoptosis increased from 0.47% (baseline) to 0.97% (1 day postoperatively). In CPB patients with complication 1.10% significantly higher (ANOVA p=0.01) comparing to CPB patients without complications. Quantitation of circulating apoptotic cells based on light scatter seems an interesting new parameter for diagnosis. Increased apoptosis of circulating lymphocytes and neutrophils further contributes to the immune suppressive response to surgery with CPB. (Support: MP, Deutsche Herzstiftung, Frankfurt, Germany)

  12. Nurse decision making regarding the use of analgesics and sedatives in the pediatric cardiac ICU.

    PubMed

    Staveski, Sandra L; Lincoln, Patricia A; Fineman, Lori D; Asaro, Lisa A; Wypij, David; Curley, Martha A Q

    2014-10-01

    To describe nurse decision making and patient responses associated with the administration of analgesics and sedatives in the pediatric cardiac ICU. Prospective nonexperimental mixed methods study of pediatric cardiac ICU nursing practice. Three tertiary academic pediatric heart centers in the United States. Pediatric cardiac ICU nurses caring for 217 patients completed 1,330 surveys. Four-item open-ended nurse survey completed each time an as needed dose of an analgesic or sedative was administered, an analgesic or sedative infusion/dose was titrated, and/or a new analgesic or sedative was administered. Responses to survey questions were entered verbatim and then collapsed using a consensus process. Collapsing of the data continued until there was a working set of "symptoms," "changes," and "clinical situation managed" categories. Nurses identified 28 symptoms managed with analgesia and sedation. The most frequent symptoms included hypertension, tachycardia, crying, pain, and agitation. Nurses identified 20 patient changes that resulted from their interventions. The most prevalent changes included improved hemodynamics, calm state, sleep, comfort, and relaxed state. Nurses identified 22 clinical situations that they were attempting to manage. The most frequent clinical situations included pain, hemodynamics, procedures, hypertension, and agitation. Nurses responded that 22% of their interventions were influenced by others. Pediatric cardiac ICU nurses use many nonspecific indicators to describe patient level of comfort collectively. Decisions for managing patient comfort were influenced by their patients' overall hemodynamic stability.

  13. The Effect of Antifibrinolytic Prophylaxis on Postoperative Outcomes in Patients Undergoing Cardiac Operations

    PubMed Central

    Koul, Abhinav; Ferraris, Victor; Davenport, Daniel L; Ramaiah, Chandrashekhar

    2012-01-01

    Antifibrinolytic agents such as aprotinin and epsilon aminocaproic acid limit postoperative bleeding and blood transfusion in patients undergoing cardiac operations using cardiopulmonary bypass (CPB). Recent evidence suggests that these agents have adverse side effects that influence operative mortality and morbidity. We studied postoperative bleeding, transfusion rates, and operative outcomes in our patients in order to assess the efficacy of these agents during cardiac operations requiring CPB. We reviewed records of 520 patients undergoing a variety of cardiac operations between January 2005 and May 2009. We measured multiple variables including pre-operative risk factors, antifibrinolytic agent used, and outcomes of operation, such as measures of bleeding and blood transfusion, as well as serious operative morbidity and mortality. Postoperative bleeding rates varied significantly between patients receiving aprotinin and those receiving aminocaproic acid (P < 0.05). There was an associated 12% decrease in operative site bleeding in aprotinin-treated patients compared with aminocaproic acid. There was no significant difference in the transfusion rates of packed red blood cells between patients receiving aminocaproic acid or aprotinin (P > 0.05), though individuals in the aprotinin group did receive FFP more frequently than patients in the aminocaproic acid group (P < 0.05). There was no significant difference in morbidity and mortality rates between patients in either drug group (P > 0.05). Our study shows that aprotinin is more effective at controlling operative site bleeding than aminocaproic acid. Reduced operative site bleeding did not portend better outcome or differences in transfusion requirements. Aminocaproic acid remains a safe and cost-effective option for antifibrinolytic prophylaxis because of unavailability of aprotinin. PMID:23101999

  14. Postoperative costs associated with outcomes after cardiac surgery with extracorporeal circulation: role of antithrombin levels.

    PubMed

    Muedra, Vicente; Llau, Juan V; Llagunes, José; Paniagua, Pilar; Veiras, Sonia; Fernández-López, Antonio R; Diago, Carmen; Hidalgo, Francisco; Gil, Jesús; Valiño, Cristina; Moret, Enric; Gómez, Laura; Pajares, Azucena; de Prada, Blanca

    2013-04-01

    To study the impact on postoperative costs of a patient's antithrombin levels associated with outcomes after cardiac surgery with extracorporeal circulation. An analytic decision model was designed to estimate costs and clinical outcomes after cardiac surgery in a typical patient with low antithrombin levels (<63.7%) compared with a patient with normal antithrombin levels (≥63.7%). The data used in the model were obtained from a literature review and subsequently validated by a panel of experts in cardiothoracic anesthesiology. Multi-institutional (14 Spanish hospitals). Consultant anesthesiologists. A sensitivity analysis of extreme scenarios was carried out to assess the impact of the major variables in the model results. The average cost per patient was €18,772 for a typical patient with low antithrombin levels and €13,881 for a typical patient with normal antithrombin levels. The difference in cost was due mainly to the longer hospital stay of a patient with low antithrombin levels compared with a patient with normal levels (13 v 10 days, respectively, representing a €4,596 higher cost) rather than to costs related to the management of postoperative complications (€215, mostly owing to transfusions). Sensitivity analysis showed a high variability range of approximately ±55% of the base case cost between the minimum and maximum scenarios, with the hospital stay contributing more significantly to the variation. Based on this analytic decision model, there could be a marked increase in the postoperative costs of patients with low antithrombin activity levels at the end of cardiac surgery, mainly ascribed to a longer hospitalization. Copyright © 2013 Elsevier Inc. All rights reserved.

  15. Intraoperative cell salvage during cardiac surgery is associated with reduced postoperative lung injury

    PubMed Central

    Engels, Gerwin E.; van Klarenbosch, Jan; Gu, Y. John; van Oeveren, Willem; de Vries, Adrianus J.

    2016-01-01

    OBJECTIVES In addition to its blood-sparing effects, intraoperative cell salvage may reduce lung injury following cardiac surgery by removing cytokines, neutrophilic proteases and lipids that are present in cardiotomy suction blood. To test this hypothesis, we performed serial measurements of biomarkers of the integrity of the alveolar-capillary membrane, leucocyte activation and general inflammation. We assessed lung injury clinically by the duration of postoperative mechanical ventilation and the alveolar arterial oxygen gradient. METHODS Serial measurements of systemic plasma concentrations of interleukin-6 (IL-6), myeloperoxidase, elastase, surfactant protein D (SP-D), Clara cell 16 kD protein (CC16) and soluble receptor for advanced glycation endproducts (sRAGEs) were performed on blood samples from 195 patients who underwent cardiac surgery with the use of a cell salvage (CS) device (CS, n = 99) or without (CONTROL, n = 96). RESULTS Postoperative mechanical ventilation time was shorter in the CS group than in the CONTROL group [10 (8–15) vs 12 (9–18) h, respectively, P = 0.047]. The postoperative alveolar arterial oxygen gradient, however, was not different between groups. After surgery, the lung injury biomarkers CC16 and sRAGEs were lower in the CS group than in the CONTROL group. Biomarkers of systemic inflammation (IL-6, myeloperoxidase and elastase) were also lower in the CS group. Finally, mechanical ventilation time correlated with CC16 plasma concentrations. CONCLUSIONS The intraoperative use of a cell salvage device resulted in less lung injury in patients after cardiac surgery as assessed by lower concentrations of lung injury markers and shorter mechanical ventilation times. PMID:26705299

  16. Population pharmacokinetic modeling of hydromorphone in cardiac surgery patients during postoperative pain therapy.

    PubMed

    Jeleazcov, Christian; Saari, Teijo I; Ihmsen, Harald; Mell, Jan; Fröhlich, Katharina; Krajinovic, Ljubica; Fechner, Jörg; Schüttler, Jürgen

    2014-02-01

    Hydromorphone is a µ-selective opioid agonist used in postoperative pain therapy. This study aimed to evaluate the pharmacokinetics of hydromorphone in cardiac surgery patients during postoperative analgesia with target-controlled infusion and patient-controlled analgesia. In this study, 50 adult patients were enrolled to receive intravenous hydromorphone during postoperative pain therapy. Arterial plasma samples were collected for measurements of drug concentration. Population pharmacokinetic parameters were estimated using nonlinear mixed-effects modeling. Results were validated and simulations were carried out to evaluate results. Data from 49 patients (age range, 40-81 yr) were analyzed. The pharmacokinetics of hydromorphone were best described by a three-compartment model. Age was incorporated as a significant covariate for elimination clearance and central volume of distribution. Scaling all parameters with body weight improved the model significantly. The final estimates of the model parameters for the typical adult patient (67 yr old, weighing 70 kg) undergoing cardiac surgery were as follows: CL1 = 1.01 l/min, V1 = 3.35 l, CL2 = 1.47 l/min, V2 = 13.9 l, CL3 = 1.41 l/min, and V3 = 145 l. The elimination clearance decreased by 43% between the age of 40 and 80 yr, and simulations demonstrated that context-sensitive half-time increased from 26 to 84 min in 40- and 80-yr-old subjects, respectively. The final pharmacokinetic model gave a robust representation of hydromorphone pharmacokinetics. Inclusion of age and body weight to the model demonstrated a significant influence of these covariates on hydromorphone pharmacokinetics. The application of this patient-derived population model in individualized pain therapy should improve the dosing of hydromorphone in patients undergoing cardiac surgery.

  17. Can nurse-led preoperative education reduce anxiety and postoperative complications of patients undergoing cardiac surgery?

    PubMed

    Kalogianni, Antonia; Almpani, Panagiota; Vastardis, Leonidas; Baltopoulos, George; Charitos, Christos; Brokalaki, Hero

    2016-10-01

    The effect of preoperative education on anxiety and postoperative outcomes of cardiac surgery patients remains unclear. The aim of the study was to estimate the effectiveness of a nurse-led preoperative education on anxiety and postoperative outcomes. A randomised controlled study was designed. All the patients who were admitted for elective cardiac surgery in a general hospital in Athens with knowledge of the Greek language were eligible to take part in the study. Patients in the intervention group received preoperative education by specially trained nurses. The control group received the standard information by the ward personnel. Measurements of anxiety were conducted on admission-A, before surgery-B and before discharge-C by the state-trait anxiety inventory. The sample consisted of 395 patients (intervention group: 205, control group: 190). The state anxiety on the day before surgery decreased only in the intervention group (34.0 (8.4) versus 36.9 (10.7); P=0.001). The mean decrease in state score during the follow-up period was greater in the intervention group (P=0.001). No significant difference was found in the length of stay or readmission. Lower proportions of chest infection were found in the intervention group (10 (5.3) versus 1 (0.5); P=0.004). Multivariate linear regression revealed that education and score in trait anxiety scale on admission are independent predictors of a reduction in state anxiety. Preoperative education delivered by nurses reduced anxiety and postoperative complications of patients undergoing cardiac surgery, but it was not effective in reducing readmissions or length of stay. © The European Society of Cardiology 2015.

  18. Patient participation in pulmonary interventions to reduce postoperative pulmonary complications following cardiac surgery.

    PubMed

    McTier, Lauren; Botti, Mari; Duke, Maxine

    2016-02-01

    Clinical interventions aimed at reducing the incidence of postoperative pulmonary complications necessitate patient engagement and participation in care. Patients' ability and willingness to participate in care to reduce postoperative complications is unclear. Further, nurses' facilitation of patient participation in pulmonary interventions has not been explored. To explore patients' ability and willingness to participate in pulmonary interventions and nurses' facilitation of pulmonary interventions. Single institution, case study design. Multiple methods of data collection were used including preadmission (n=130) and pre-discharge (n=98) patient interviews, naturalistic observations (n=48) and nursing focus group interviews (n=2). A cardiac surgical ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia. One hundred and thirty patients admitted for cardiac surgery via the preadmission clinic during a 1-year period and 40 registered nurses who were part of the permanent workforce on the cardiac surgical ward. Patients' understanding of their role in pulmonary interventions and patients' preference for and reported involvement in pulmonary management. Nurses' facilitation of patients to participate in pulmonary interventions. Patients displayed a greater understanding of their role in pulmonary interventions after their surgical admission than they did at preadmission. While 55% of patients preferred to make decisions about deep breathing and coughing exercises, three-quarters of patients (75%) reported they made decisions about deep breathing and coughing during their surgical admission. Nurses missed opportunities to engage patients in this aspect of pulmonary management. Patients appear willing to take responsibility for pulmonary management in the postoperative period. Nurses could enhance patient participation in pulmonary interventions by ensuring adequate information and education is provided. Facilitation of patients' participation

  19. Clinical indicators of ineffective airway clearance for patients in the cardiac postoperative period.

    PubMed

    de Sousa, Vanessa Emille Carvalho; de Oliveira Lopes, Marcos Venícios; de Araujo, Thelma Leite; Rolim, Isaura Letícia Tavares Palmeira; do Nascimento, Ranielly Vidal; Oliveira, Talita Ferreira

    2013-04-01

    The accuracy of an indicator determines the direct relationship between a defining characteristic and the presence or absence of a specific nursing diagnosis. To analyse the accuracy of the clinical indicators of ineffective airway clearance in patients during the postoperative period of cardiac surgery. A total of 98 patients recruited from a postoperative unit were included in the study. An analysis of sensitivity, specificity, predictive value, likelihood ratio, diagnostic odds ratio, accuracy, and area under the ROC curve was used to determine the accuracy of these clinical indicators. Four clinical indicators showed the highest levels of accuracy by statistical measure: dyspnoea, adventitious breath sounds, ineffective cough, and retained secretions. The indicators retained secretions and ineffective cough showed high diagnostic odds ratios (62.8 and 28.1, respectively). The results suggest that there are differences between the ineffective airway clearance indicators as accuracy measures.

  20. Mothers' view on late postoperative pain management by the nursing team in children after cardiac surgery.

    PubMed

    Nascimento, Lucila Castanheira; Strabelli, Brisa Soldatelli; de Almeida, Fernanda Cristina Queiroz Gomes; Rossato, Lisabelle Mariano; Leite, Adriana Moraes; de Lima, Regina Aparecida Garcia

    2010-01-01

    Postoperative pain management in children is a complex, multidimensional and subjective phenomenon. It represents a challenge for children, parents and health professionals. This study aimed to understand how mothers assess their children's pain management by the nursing team in the late postoperative phase of cardiac surgery. Empirical data collection was carried out through semistructured interviews with 17 mothers who accompanied their children. Data were subject to qualitative analysis, revealing that, for the mothers, taking good care results from the confidence they vest in the nursing team and from the observation of the medication interventions this team performs. Not taking good care of their children is a consequence of lack of information or inadequate communication between the team and the mothers. The results of this study permit identifying aspects that strengthen and weaken nursing care for these clients, contributing to the improvement of the delivered care.

  1. Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery.

    PubMed

    Katsura, Morihiro; Kuriyama, Akira; Takeshima, Taro; Fukuhara, Shunichi; Furukawa, Toshi A

    2015-10-05

    Postoperative pulmonary complications (PPCs) have an impact on the recovery of adults after surgery. It is therefore important to establish whether preoperative respiratory rehabilitation can decrease the risk of PPCs and to identify adults who might benefit from respiratory rehabilitation. Our primary objective was to assess the effectiveness of preoperative inspiratory muscle training (IMT) on PPCs in adults undergoing cardiac or major abdominal surgery. We looked at all-cause mortality and adverse events. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), MEDLINE (1966 to October 2014), EMBASE (1980 to October 2014), CINAHL (1982 to October 2014), LILACS (1982 to October 2014), and ISI Web of Science (1985 to October 2014). We did not impose any language restrictions. We included randomized controlled trials that compared preoperative IMT and usual preoperative care for adults undergoing cardiac or major abdominal surgery. Two or more review authors independently identified studies, assessed trial quality, and extracted data. We extracted the following information: study characteristics, participant characteristics, intervention details, and outcome measures. We contacted study authors for additional information in order to identify any unpublished data. We included 12 trials with 695 participants; five trials included participants awaiting elective cardiac surgery and seven trials included participants awaiting elective major abdominal surgery. All trials contained at least one domain judged to be at high or unclear risk of bias. Of greatest concern was the risk of bias associated with inadequate blinding, as it was impossible to blind participants due to the nature of the study designs. We could pool postoperative atelectasis in seven trials (443 participants) and postoperative pneumonia in 11 trials (675 participants) in a meta-analysis. Preoperative IMT was associated with a reduction of postoperative atelectasis and

  2. Cardiac biomarkers in pediatric heart disease: A state of art review

    PubMed Central

    Fernandes, Benedict A; Maher, Kevin O; Deshpande, Shriprasad R

    2016-01-01

    Every year there are more than 11000 hospitalizations related to heart failure in children resulting in significant morbidity and mortality. Over the last two decades, our understanding, diagnosis and management of pediatric heart failure is evolving but our ability to prognosticate outcomes in pediatric heart acute heart failure is extremely limited due to lack of data. In adult heart failure patients, the role of cardiac biomarkers has exponentially increased over the last two decades. Current guidelines for management of heart failure emphasize the role of cardiac biomarkers in diagnosis, management and prognostication of heart failure. It is also noteworthy that these biomarkers reflect important biological processes that also open up the possibility of therapeutic targets. There is however, a significant gap present in the pediatric population with regards to biomarkers in pediatric heart failure. Here, we seek to review available data regarding cardiac biomarkers in the pediatric population and also explore some of the emerging biomarkers from adult literature that may be pertinent to pediatric heart failure. PMID:28070239

  3. Postoperative atrial fibrillation and total dietary antioxidant capacity in patients undergoing cardiac surgery: The Polyphemus Observational Study.

    PubMed

    Costanzo, Simona; De Curtis, Amalia; di Niro, Veronica; Olivieri, Marco; Morena, Mariarosaria; De Filippo, Carlo Maria; Caradonna, Eugenio; Krogh, Vittorio; Serafini, Mauro; Pellegrini, Nicoletta; Donati, Maria Benedetta; de Gaetano, Giovanni; Iacoviello, Licia

    2015-04-01

    Postoperative atrial fibrillation is a major cause of morbidity and mortality for stroke after cardiac surgery. Both systemic inflammation and oxidative stress play a role in the initiation of postoperative atrial fibrillation after cardiac surgery. The possible association between long-term intake of antioxidant-rich foods and postoperative atrial fibrillation incidence was examined in patients undergoing cardiac surgery. A total of 217 consecutive patients (74% were men; median age, 68.4 years) undergoing cardiac surgery, mainly coronary artery bypass grafting and valve replacement or repair, were recruited from January 2010 to September 2012. Total antioxidant capacity was measured in foods by the Trolox equivalent antioxidant capacity assay. The European Prospective Investigation into Cancer and Nutrition Food Frequency Questionnaire was used for dietary total antioxidant capacity assessment. The association among tertiles of dietary total antioxidant capacity and postoperative atrial fibrillation incidence was assessed using multivariable logistic analysis. The overall incidence of total arrhythmias and postoperative atrial fibrillation was 42.4% and 38.2%, respectively. In multivariable analysis, after adjustment for age, gender, use of hypoglycemic drugs, physical activity, education, previous diagnosis of atrial fibrillation, and total energy intake, patients in the highest tertile of dietary total antioxidant capacity had a lower risk of postoperative atrial fibrillation than patients in the 2 lowest tertiles (odds ratio, 0.46; 95% confidence interval, 0.22-0.95; P = .048). A restricted cubic spline transformation confirmed the nonlinear relationship between total antioxidant capacity (in continuous scale) and postoperative atrial fibrillation (P = .023). When considering only coronary artery bypass grafting, valve replacement/repair, and combined surgeries, the protective effect on postoperative atrial fibrillation of a diet rich in antioxidants was

  4. [Postoperative mortality a university Department of General Surgery: incidence of cardiac-related deaths].

    PubMed

    Tavernier, B; Sanchez, R; Pattou, F; Mallat, J; Sperandio, M; Proye, C

    2000-01-01

    To evaluate the incidence of cardiac deaths following noncardiac nonvascular surgery. Retrospective survey. All patients undergoing mainly endocrinous and digestive surgery in a University department of general surgery between 1991 and 1996. Analysis of all deaths occurring intra- and postoperatively, until discharge of the patients. Demographic and medical data, including patent myocardial ischaemia and risk factors for coronary artery disease, were recorded and compared with a control group including all patients undergoing surgery from January to September 1996. In the 8,700 patients who underwent mainly endocrine neck surgery (66%), or intra-abdominal surgery (31%), the mortality rate (n = 96) was 1.1% (95% confidence interval [95% CI] = 0.9-1.3%). Patent myocardial ischaemia or high risk factors for coronary artery disease were existing in 24% of patients with neck surgery, 31% of those with intra-abdominal surgery, and in 60% of the deceased patients (P < 0.01 vs control group). Those who died were older, were in a higher ASA physical class, and had undergone an emergency procedure more often than patients of the control group (P < 0.002 for each parameter). Two cardiac deaths, in patients with a patent cardiopathy, were recorded (cardiac mortality: 0.02%; 95% CI = 0.003-0.08%). The main cause of death was infection (n = 46), followed by haemorrhage (n = 12). Seven deaths remained unexplained. This study suggests that cardiac morbidity is a rare cause of death after noncardiac nonvascular surgery.

  5. Correlation of a novel noninvasive tissue oxygen saturation monitor to serum central venous oxygen saturation in pediatric patients with postoperative congenital cyanotic heart disease.

    PubMed

    Yadlapati, Ajay; Grogan, Tristan; Elashoff, David; Kelly, Robert B

    2013-03-01

    Using a novel noninvasive, visible-light optical diffusion oximeter (T-Stat VLS Tissue Oximeter; Spectros Corporation, Portola Valley, CA) to measure the tissue oxygen saturation (StO2) of the buccal mucosa, the correlation between StOz and central venous oxygen saturation (ScvO2) was examined in children with congenital cyanotic heart disease undergoing a cardiac surgical procedure. Paired StO2 and serum ScvO2 measurements were obtained postoperatively and statistically analyzed for agreement and association. Thirteen children (nine male) participated in the study (age range, 4 days to 18 months). Surgeries included Glenn shunt procedures, Norwood procedures, unifocalization procedures with Blalock-Taussig shunt placement, a Kawashima/ Glenn shunt procedure, a Blalock-Taussig shunt placement, and a modified Norwood procedure. A total of 45 paired StO2-ScvO2 measurements was obtained. Linear regression demonstrated a Pearson's correlation of .58 (95% confidence interval [CI], .35-.75; p < .0001). The regression slope coefficient estimate was .95 (95% CI, .54-1.36) with an interclass correlation coefficient of .48 (95% CI, .22-.68). Below a clinically relevant average ScvO2 value, a receiver operator characteristic analysis yielded an area under the curve of .78. Statistical methods to control for repeatedly measuring the same subjects produced similar results. This study shows a moderate relationship and agreement between StO2 and ScvO2 measurements in pediatric patients with a history of congenital cyanotic heart disease undergoing a cardiac surgical procedure. This real-time monitoring device can act as a valuable adjunct to standard noninvasive monitoring in which serum SyvO2 sampling currently assists in the diagnosis of low cardiac output after pediatric cardiac surgery.

  6. Preventing Long-Term Cardiac Damage in Pediatric Patients With Kawasaki Disease.

    PubMed

    Williams, Kelly

    Kawasaki disease is currently the leading cause of long-term cardiac damage in pediatric patients in the United States. Kawasaki disease is diagnosed based on symptomatology and by ruling out other etiology. There is a significant need for an improved, standardized treatment protocol for patients diagnosed with Kawasaki disease and a more rapid initiation of treatment for these patients. Decreasing the cardiac damage caused by Kawasaki disease with timely diagnosis and treatment needs be a principal goal.

  7. Pediatric Thyroid Cancer: Postoperative Classifications and Response to Initial Therapy as Prognostic Factors.

    PubMed

    Lazar, Liora; Lebenthal, Yael; Segal, Karl; Steinmetz, Adam; Strenov, Yulia; Cohen, Maya; Yaniv, Isaac; Yackobovitch-Gavan, Michal; Phillip, Moshe

    2016-05-01

    Prognostic factors for pediatric differentiated thyroid cancer (DTC) are not well established. The objective of the study was to retrospectively compare the postoperative risk-stratification systems: American Thyroid Association (ATA) risk categories, Schneider Children's Medical Center of Israel (SCMCI) score, and the response to initial therapy as predictors for disease outcome. Fifty-four DTC patients, median age at diagnosis 13.9 years (range 1.9-17 y), followed up for a median of 8.8 years (range 2.6-20.5 y) were stratified into prepubertal (n = 9), pubertal (n = 25), and postpubertal (n = 20) groups. All patients underwent total/near-total thyroidectomy; 48 received radioiodine therapy. The extent of DTC was evaluated by applying the ATA risk categories and the novel SCMCI score. Postoperative risk stratifications (low/intermediate/high) were determined using histopathological, laboratory, and imaging findings. Response to initial therapy (complete/acceptable/incomplete) was based on stimulated thyroglobulin and imaging results during the first 2 years of follow-up. The risk for recurrent/persistent disease, as assessed by the postoperative ATA risk-stratification system and the SCMCI score and by the response to initial therapy, was higher in the prepubertal group (P < .001, P = .002, and P = .02, respectively). Outcome prediction by the risk-stratification systems was applicable: ATA risk categories, P = .014, R(2) = 0.247, predictive ability 80.4%; SCMCI score, P < .001, R(2) = 0.435, predictive ability 86.3%; and response to initial therapy stratification, P < .001, R(2) = 0.789, predictive ability 96.1%. The proportion of variance explained by the ATA risk categories (0.25), SCMCI score (0.44), and response to initial therapy (0.79) indicated that the latter was the most precise predictor and that the SCMCI score reflected the disease outcome better than ATA risk categories. Our data confirm that the postoperative pediatric ATA stratification system and

  8. Factors affecting survival in pediatric cardiac tamponade caused by central venous catheters.

    PubMed

    Kayashima, Kenji

    2015-12-01

    Pediatric central venous catheter (CVC) placement is useful but associated with complications such as cardiac tamponade. We aimed to identify risk factors for death in cardiac tamponade. Published articles on pediatric CVC-associated cardiac tamponade were obtained by searching PubMed and Google and retrospectively reviewed to analyze risk factors for death. Factors examined for their effect on mortality risk included patient age, weight, CVC size, days from CVC insertion to tamponade occurrence, substances administered, insertion site, treatment, CVC material, and initial CVC tip position. Of 110 patients reported in 62 articles, 69 survived and 41 died. Among survivors, 55 of 69 patients were treated; among deaths, only 7 of 38 (OR 537.9, 95% CI 29.3-9,877, p < 0.0001). Multiple regression analysis in 44 cases showed that treatment (p < 0.0001) and initial CVC tip position (p = 0.020) were independent predictive factors related to improved cardiac tamponade survival. Past studies have mainly discussed how to avoid pediatric cardiac tamponade; by contrast, the present study focused on how to avoid deaths. The findings of this review suggest that cardiac tamponade survival is better when tamponade is detected early and treated promptly and might be affected by initial CVC tip position.

  9. Dysfunction of pre- and post-operative cardiac autonomic nervous system in elderly patients with diabetes mellitus.

    PubMed

    Zhang, Junlong; Tu, Weifeng; Dai, Jianqiang; Lv, Qing; Yang, Xiaoqi

    2011-01-01

    The pre- and post-operative cardiac autonomic nervous functions were compared in elderly, non-cardiac surgery patients with diabetes mellitus (DM) and without diabetes mellitus (NDM). A group of 30 unpremedicated elderly patients scheduled to undergo elective non-cardiac surgery were studied, including 15 DM patients and 15 NDM patients. Each component of heart rate variability (HRV) analysis in the frequency domain was monitored with Holter during the nights of the day before and on 1st and 2nd day after operation. After surgery, total power (TP), high frequency (HF), low frequency (LF) and very low frequency (VLF) significantly decreased as compared to the baseline values before operation in both groups (p<0.05). The LF/HF ratio was significantly changed in DM group but did not change in NDM group. On the 2nd postoperative day, TP, HF, LF and VLF in DM group were further decreased as compared to those on the 1st postoperative day and were significantly lower than those in NDM group (p<0.01 or 0.05), but these indices in NDM group did not show significant decreases. Surgery induced the cardiac autonomic nervous dysfunction in elderly patients not only with DM but also without diabetes. On the 2nd postoperative day, the disturbances of cardiac autonomic nervous activity were more sever in DM patients, compared to the 1st postoperative day, but was not significantly more sever than in the NDM patients.

  10. Pancreatic stone protein predicts postoperative infection in cardiac surgery patients irrespective of cardiopulmonary bypass or surgical technique.

    PubMed

    Klein, Holger J; Csordas, Adam; Falk, Volkmar; Slankamenac, Ksenija; Rudiger, Alain; Schönrath, Felix; Rodriguez Cetina Biefer, Hector; Starck, Christoph T; Graf, Rolf

    2015-01-01

    We investigated the role of pancreatic stone protein (PSP) in predicting the occurrence of infection in the postoperative course of cardiac surgery patients. Several biomarkers indicating the presence of inflammation and infection are available in the clinical routine; yet, their utility in the postoperative course of patients following cardiac surgery remains uncertain. Moreover, cardiopulmonary bypass, also referred to as "on-pump surgery", increases the susceptibility to an exaggerated inflammatory state. However, the impact of such extracorporeal circulation on circulating PSP levels remains poorly understood. In a prospective cohort of unselected patients undergoing cardiac surgery, we set out to elucidate the diagnostic accuracy of serum PSP levels as opposed to canonical biomarkers (CRP, WBC) of inflammation to discriminate between the presence of infection and surgical trauma,. In addition, we investigated whether the biomarkers were influenced by the surgical technique employed, i.e. on-pump vs. off-pump and minimally invasive surgery vs. sternotomy. Levels of circulating PSP and routine inflammatory biomarkers (CRP, WBC) were measured in samples taken from 120 patients at baseline as well as at postoperative day 1-3. Univariate analysis showed that among the biomarkers investigated, only PSP levels had discriminatory power to differentiate infection from surgical trauma in the postoperative course of the entire cohort of patients following cardiac surgery. With regard to cardiac surgical interventions, there was no significant association between the absence or presence of extracorporeal circulation and PSP levels. However, there was a significant difference in the slope of the rise of postoperative PSP between minimally invasive surgery as opposed to patients subjected to sternotomy. In an unselected population of cardiac surgery patients, post-operative serum PSP levels were significantly associated with the presence of infection in both the on-pump and

  11. Early postoperative changes in cerebral oxygen metabolism following neonatal cardiac surgery: Effects of surgical duration

    PubMed Central

    Buckley, Erin M.; Lynch, Jennifer M.; Goff, Donna A.; Schwab, Peter J.; Baker, Wesley B.; Durduran, Turgut; Busch, David R.; Nicolson, Susan C.; Montenegro, Lisa M.; Naim, Maryam Y.; Xiao, Rui; Spray, Thomas L.; Yodh, A. G.; Gaynor, J. William; Licht, Daniel J.

    2013-01-01

    Objective The early postoperative period following neonatal cardiac surgery is a time of increased risk for brain injury, yet the mechanisms underlying this risk are unknown. To understand these risks more completely, we quantified changes in postoperative cerebral metabolic rate of oxygen (CMRO2), oxygen extraction fraction (OEF), and cerebral blood flow (CBF) compared with preoperative levels by using noninvasive optical modalities. Methods Diffuse optical spectroscopy and diffuse correlation spectroscopy were used concurrently to derive cerebral blood flow and oxygen utilization postoperatively for 12 hours. Relative changes in CMRO2, OEF, and CBF were quantified with reference to preoperative data. A mixed-effect model was used to investigate the influence of total support time and deep hypothermic circulatory arrest duration on relative changes in CMRO2, OEF, and CBF. Results Relative changes in CMRO2, OEF, and CBF were assessed in 36 patients, 21 with single-ventricle defects and 15 with 2-ventricle defects. Among patients with single-ventricle lesions, deep hypothermic circulatory arrest duration did not affect relative changes in CMRO2, CBF, or OEF (P > .05). Among 2-ventricle patients, total support time was not a significant predictor of relative changes in CMRO2 or CBF (P > .05), although longer total support time was associated significantly with greater increases in relative change of postoperative OEF (P = .008). Conclusions Noninvasive diffuse optical techniques were used to quantify postoperative relative changes in CMRO2, CBF, and OEF for the first time in this observational pilot study. Pilot data suggest that surgical duration does not account for observed variability in the relative change in CMRO2, and that more comprehensive clinical studies using the new technology are feasible and warranted to elucidate these issues further. PMID:23111021

  12. Pain locations in the postoperative period after cardiac surgery: Chronology of pain and response to treatment.

    PubMed

    Roca, J; Valero, R; Gomar, C

    Postoperative pain after cardiac surgery (CS) can be generated at several foci besides the sternotomy. Prospective descriptive longitudinal study on the chronological evolution of pain in 11 sites after CS including consecutive patients submitted to elective CS through sternotomy. The primary endpoints were to establish the main origins of pain, and to describe its chronological evolution during the first postoperative week. Secondary endpoints were to describe pain characteristics in the sternotomy area and to correlate pain intensity with other variables. Numerical Pain Rating Scale from 0 to 10 at rest and at movement on postoperative days 1, 2, 4 and 6. Numerical Pain Rating Scale>3 was considered moderate pain. Statistical analysis consisted in Mann-Whitney U-test, a Chi-squared, a Fisher exact text and Pearson's correlations. Forty-seven patients were enrolled. In 4 of 11 locations pain was reported as Numerical Pain Rating Scale>3 (sternotomy, oropharynx, saphenectomy and musculoskeletal pain in the back and shoulders). Maximum intensity of pain on postoperative days 1 and 2 was reported in the sternotomy area, while on postoperative days 4 and 6 it was reported at the saphenectomy. Pain at rest and at movement differed considerably in the sternotomy, saphenectomy and oropharynx. Pain at back and shoulders and at central venous catheter entry were not influenced by movement. Pain in the sternotomy was mainly described as oppressive. Patients with arthrosis and younger patients presented higher intensity of pain (P=.004; P=.049, respectively). Four locations were identified as the main sources of pain after CS: sternotomy, oropharynx, saphenectomy, and back and shoulders. Pain in different focuses presented differences in chronologic evolution and was differently influenced by movement. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

  13. [The use of central acting analgesic nefopam in postoperative analgesia in cardiac surgery patients].

    PubMed

    Eremenko, A A; Sorokina, L S; Pavlov, M V

    2013-01-01

    A prospective, randomized, comparative study was conducted. 3 analgesia protocols were used: 1) patient controlled analgesia (PCA) with trimeperidine in combination with a nefopam constant infusion; 2) PCA with trimeperidine in combination with a nefopam bolus; 3) PCA with trimeperidine separately during early postoperative period in cardiac surgery patients. The study included 60 patients agedf rom 40 to 65 years of age (20 patients in each group). The analgesia efficacy was evaluated with a 5-point verbal rating scale (VRS) for pain intensity and inspiratory lung capacity (ILC), measured with incentive spirometer. The safety of nefopam during early postoperative period in cardiac surgery patients was shown. The combination of nefopam and trimeperidine led to a more pronounced analgetic effect. Trimeperidine consumption was significantly lower in nefopam groups than in the group of isolated PCA. Wholly adverse effects were associated with trimeperidine and were dose-related The incidence of nausea, vomiting, dizziness, weakness, bowel paresis was significantly higher in isolated PCA group than in the other two groups.

  14. Reiki therapy for postoperative oral pain in pediatric patients: Pilot data from a double-blind, randomized clinical trial

    PubMed Central

    Kundu, Anjana; Lin, Yuting; Oron, Assaf P.; Doorenbos, Ardith Z.

    2014-01-01

    Purpose To examine the effects of Reiki as an adjuvant therapy to opioid therapy for postoperative pain control in pediatric patients. Methods This was a double-blind, randomized controlled study of children undergoing dental procedures. Participants were randomly assigned to receive either Reiki therapy or the control therapy (sham Reiki) preoperatively. Postoperative pain scores, opioid requirements, and side effects were assessed. Family members were also asked about perioperative care satisfaction. Multiple linear regressions were used for analysis. Results Thirty-eight children participated. The blinding procedure was successful. No statistically significant difference was observed between groups on all outcome measures. Implications Our study provides a successful example of a blinding procedure for Reiki therapy among children in the perioperative period. This study does not support the effectiveness of Reiki as an adjuvant therapy to opioid therapy for postoperative pain control in pediatric patients. PMID:24439640

  15. Reiki therapy for postoperative oral pain in pediatric patients: pilot data from a double-blind, randomized clinical trial.

    PubMed

    Kundu, Anjana; Lin, Yuting; Oron, Assaf P; Doorenbos, Ardith Z

    2014-02-01

    To examine the effects of Reiki as an adjuvant therapy to opioid therapy for postoperative pain control in pediatric patients. This was a double-blind, randomized controlled study of children undergoing dental procedures. Participants were randomly assigned to receive either Reiki therapy or the control therapy (sham Reiki) preoperatively. Postoperative pain scores, opioid requirements, and side effects were assessed. Family members were also asked about perioperative care satisfaction. Multiple linear regressions were used for analysis. Thirty-eight children participated. The blinding procedure was successful. No statistically significant difference was observed between groups on all outcome measures. Our study provides a successful example of a blinding procedure for Reiki therapy among children in the perioperative period. This study does not support the effectiveness of Reiki as an adjuvant therapy to opioid therapy for postoperative pain control in pediatric patients. Copyright © 2013 Elsevier Ltd. All rights reserved.

  16. The improvement of care for paediatric and congenital cardiac disease across the World: a challenge for the World Society for Pediatric and Congenital Heart Surgery.

    PubMed

    Tchervenkov, Christo I; Jacobs, Jeffrey Phillip; Bernier, Pierre-Luc; Stellin, Giovanni; Kurosawa, Hiromi; Mavroudis, Constantine; Jonas, Richard A; Cicek, Sertac M; Al-Halees, Zohair; Elliott, Martin J; Jatene, Marcelo B; Kinsley, Robin H; Kreutzer, Christian; Leon-Wyss, Juan; Liu, Jinfen; Maruszewski, Bohdan; Nunn, Graham R; Ramirez-Marroquin, Samuel; Sandoval, Nestor; Sano, Shunji; Sarris, George E; Sharma, Rajesh; Shoeb, Ayman; Spray, Thomas L; Ungerleider, Ross M; Yangni-Angate, Hervé; Ziemer, Gerhard

    2008-12-01

    The diagnosis and treatment for paediatric and congenital cardiac disease has undergone remarkable progress over the last 60 years. Unfortunately, this progress has been largely limited to the developed world. Yet every year approximately 90% of the more than 1,000,000 children who are born with congenital cardiac disease across the world receive either suboptimal care or are totally denied care.While in the developed world the focus has changed from an effort to decrease post-operative mortality to now improving quality of life and decreasing morbidity, which is the focus of this Supplement, the rest of the world still needs to develop basic access to congenital cardiac care. The World Society for Pediatric and Congenital Heart Surgery [http://www.wspchs.org/] was established in 2006. The Vision of the World Society is that every child born anywhere in the world with a congenital heart defect should have access to appropriate medical and surgical care. The Mission of the World Society is to promote the highest quality comprehensive care to all patients with pediatric and/or congenital heart disease, from the fetus to the adult, regardless of the patient's economic means, with emphasis on excellence in education, research and community service.We present in this article an overview of the epidemiology of congenital cardiac disease, the current and future challenges to improve care in the developed and developing world, the impact of the globalization of cardiac surgery, and the role that the World Society should play. The World Society for Pediatric and Congenital Heart Surgery is in a unique position to influence and truly improve the global care of children and adults with congenital cardiac disease throughout the world [http://www.wspchs.org/].

  17. [The effect of ketamine on reducing postoperative agitation after sevoflurane anesthesia in pediatric strabismus surgery].

    PubMed

    Kawaraguchi, Yoshitaka; Miyamoto, Yoshikazu; Fukumitsu, Kazuo; Taniguchi, Akihiro; Hirao, Osamu; Kitamura, Seiji; Kinouchi, Keiko

    2002-12-01

    We investigated the effect of ketamine on reducing postoperative agitation after sevoflurane anesthesia in children undergoing elective strabismus surgery. Fifty-five children, 3-9 years of age, were randomly assigned to the following three groups; ketamine (group K, n = 18), pentazocine (group P, n = 19), and flurbiprofen axetil(group F, n = 18). Group K received ketamine 1 mg.kg-1 intravenously, followed by infusion of ketamine 1 mg.kg-1.hr-1 during surgery, group P received pentazocine 0.2 mg.kg-1 intravenously after induction of anesthesia, and Group F received intravenous flurbiprofen axetil, 1 mg.kg-1 5 minutes before the end of surgery. Agitation (evaluated by Aono's four-point scale; AFPS) and awareness (evaluated by Steward score) were assessed just before tracheal extubation(T 1), 5 minutes after tracheal extubation(T 2), arrival at the ward(T 3), and 60 minutes after arrival at the ward(T 4). We considered AFPS > or = 3 patients as "agitated" and APFS < or = 2 patients as "not agitated". At T 1 and T 2, the incidence of agitation(AFPS > or = 3) in group K was less than that of group F and group P. However, in group K, more patients needed oxygen supplement after extubation. We concluded that coadministration of ketamine could be beneficial for reducing postoperative agitation after sevoflurane anesthesia in pediatric strabismus surgery.

  18. Hemoglobin-associated Oxidative Stress in the Pericardial Compartment of Post-operative Cardiac Surgery Patients

    PubMed Central

    Kramer, Philip A.; Chacko, Balu K.; Ravi, Saranya; Johnson, Michelle S.; Mitchell, Tanecia; Barnes, Stephen; Arabshahi, Alireza; Dell’Italia, Louis J.; George, David J.; Steele, Chad; George, James F.; Darley-Usmar, Victor M.; Melby, Spencer J.

    2015-01-01

    Atherosclerosis and valvular heart disease often require treatment with corrective surgery to prevent future myocardial infarction, ischemic heart disease, and heart failure. Mechanisms underlying the development of the associated complications of surgery are multifactorial and have been linked to inflammation and oxidative stress, classically as measured in the blood or plasma of patients. Post-operative pericardial fluid (PO-PCF) has not been investigated in depth with respect to the potential to induce oxidative stress. This is important since cardiac surgery disrupts the integrity of the pericardial membrane surrounding the heart, and causes significant alterations in the composition of the pericardial fluid (PCF). This includes contamination with hemolyzed blood and high concentrations of oxidized hemoglobin, which suggests that cardiac surgery results in oxidative stress within the pericardial space. Accordingly, we tested the hypothesis that PO-PCF is highly pro-oxidant and that the potential interaction between inflammatory cell-derived hydrogen peroxide with hemoglobin is associated with oxidative stress. Blood and PCF were collected from 31 patients at the time of surgery and postoperatively from 4 to 48 hours after coronary artery bypass grafting, valve replacement, or valve repair (mitral or aortic). PO-PCF contained high concentrations of neutrophils and monocytes which are capable of generating elevated amounts of superoxide and hydrogen peroxide through the oxidative burst. In addition, PO-PCF primed naïve neutrophils resulting in an enhanced oxidative burst upon stimulation. The PO-PCF also contained increased concentrations of cell-free oxidized hemoglobin which was associated with elevated levels of F2α-isoprostanes and prostaglandins, consistent with both oxidative stress and activation of cyclooxygenase. Lastly, protein analysis of the PO-PCF revealed evidence of protein thiol oxidation and protein carbonylation. We conclude that PO-PCF is

  19. Postoperative Biomarkers Predict Acute Kidney Injury and Poor Outcomes after Adult Cardiac Surgery

    PubMed Central

    Coca, Steven G.; Thiessen-Philbrook, Heather; Shlipak, Michael G.; Koyner, Jay L.; Wang, Zhu; Edelstein, Charles L.; Devarajan, Prasad; Patel, Uptal D.; Zappitelli, Michael; Krawczeski, Catherine D.; Passik, Cary S.; Swaminathan, Madhav; Garg, Amit X.

    2011-01-01

    Acute kidney injury (AKI) is a frequent complication of cardiac surgery and increases morbidity and mortality. The identification of reliable biomarkers that allow earlier diagnosis of AKI in the postoperative period may increase the success of therapeutic interventions. Here, we conducted a prospective, multicenter cohort study involving 1219 adults undergoing cardiac surgery to evaluate whether early postoperative measures of urine IL-18, urine neutrophil gelatinase-associated lipocalin (NGAL), or plasma NGAL could identify which patients would develop AKI and other adverse patient outcomes. Urine IL-18 and urine and plasma NGAL levels peaked within 6 hours after surgery. After multivariable adjustment, the highest quintiles of urine IL-18 and plasma NGAL associated with 6.8-fold and 5-fold higher odds of AKI, respectively, compared with the lowest quintiles. Elevated urine IL-18 and urine and plasma NGAL levels associated with longer length of hospital stay, longer intensive care unit stay, and higher risk for dialysis or death. The clinical prediction model for AKI had an area under the receiver-operating characteristic curve (AUC) of 0.69. Urine IL-18 and plasma NGAL significantly improved the AUC to 0.76 and 0.75, respectively. Urine IL-18 and plasma NGAL significantly improved risk prediction over the clinical models alone as measured by net reclassification improvement (NRI) and integrated discrimination improvement (IDI). In conclusion, urine IL-18, urine NGAL, and plasma NGAL associate with subsequent AKI and poor outcomes among adults undergoing cardiac surgery. (Clinical Trials.gov number, NCT00774137). PMID:21836143

  20. Nurses' Attitudes Toward Clinical Research: Experience of the Therapeutic Hypothermia After Pediatric Cardiac Arrest Trials.

    PubMed

    Browning, Brittan; Page, Kent E; Kuhn, Renee L; DiLiberto, Mary Ann; Deschenes, Jendar; Taillie, Eileen; Tomanio, Elyse; Holubkov, Richard; Dean, J Michael; Moler, Frank W; Meert, Kathleen; Pemberton, Victoria L

    2016-03-01

    To understand factors affecting nurses' attitudes toward the Therapeutic Hypothermia After Pediatric Cardiac Arrest trials and association with approach/consent rates. Cross-sectional survey of pediatric/cardiac intensive care nurses' perceptions of the trials. Study was conducted at 16 of 38 self-selected study sites. Pediatric and cardiac intensive care nurses. The primary outcome was the proportion of nurses with positive perceptions, as defined by agree or strongly agree with the statement "I am happy to take care of a Therapeutic Hypothermia after Pediatric Cardiac Arrest patient". Associations between perceptions and study approach/consent rates were also explored. Of 2,241 nurses invited, 1,387 (62%) completed the survey and 77% reported positive perceptions of the trials. Nurses, who felt positively about the scientific question, the study team, and training received, were more likely to have positive perceptions of the trials (p < 0.001). Nurses who had previously cared for a research patient had significantly more positive perceptions of Therapeutic Hypothermia After Pediatric Cardiac Arrest compared with those who had not (79% vs 54%; p < 0.001). Of the 754 nurses who cared for a Therapeutic Hypothermia After Pediatric Cardiac Arrest patient, 82% had positive perceptions, despite 86% reporting it required more work. Sixty-nine percent believed that hypothermia reduces brain injury and mortality; sites had lower consent rates when their nurses believed that hypothermia was beneficial. Institution-specific approach rates were positively correlated with nurses' perceptions of institutional support for the trial (r = 0.54; p = 0.04), ICU support (r = 0.61; p = 0.02), and the importance of conducting the trial in children (r = 0.61; p = 0.01). The majority of nurses had positive perceptions of the Therapeutic Hypothermia After Pediatric Cardiac Arrest trials. Institutional, colleague, and study team support and training were contributing factors. Despite

  1. Postoperative nonsteroidal anti-inflammatory drugs and risk of bleeding in pediatric intracapsular tonsillectomy.

    PubMed

    D'Souza, Jill N; Schmidt, Richard J; Xie, Li; Adelman, Julie P; Nardone, Heather C

    2015-09-01

    In light of current FDA guidelines on opioid use in children, we sought to determine the risk of post-tonsillectomy hemorrhage (PTH) in children who received ibuprofen with acetaminophen versus those who received narcotic with acetaminophen for postoperative pain control. This was an IRB-approved retrospective chart review of patients at a tertiary-care pediatric center. The medical records of 449 children who received acetaminophen and ibuprofen following intracapsular tonsillectomy with or without adenoidectomy were reviewed (NSAID group) and compared with medical records of 1731 children who underwent intracapsular tonsillectomy and received acetaminophen with codeine or hydrocodone with acetaminophen postoperatively (narcotic group). Main outcome measure was the incidence of PTH requiring return to the operating room. Secondary outcome measures included incidence of primary PTH, secondary PTH, and postoperative evaluation in the emergency department or readmission for pain and/or dehydration. Incidence of PTH requiring return to the operating room was higher in the NSAID group (1.6%) compared with the narcotic group (0.5%), P=0.01. Incidence of primary PTH was significantly higher in the NSAID group (2%) versus the narcotic group (0.12%), P<0.0001. Incidence of secondary PTH was 3.8% in the NSAID group and 1.1% in the narcotic group (P<0.0001). Use of ibuprofen after intracapsular tonsillectomy in children is associated with statistically significant increase in PTH requiring return to the operating room, as well as an increase in overall rates of both primary and secondary PTH. Ibuprofen provides pain control that is at least equivalent to narcotic and is not associated with respiratory depression. Further study of ibuprofen use in the post-tonsillectomy patient is warranted. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  2. Cardiac myxoma causing acute ischemic stroke in a pediatric patient and a review of literature.

    PubMed

    Fuchs, Jennifer; Leszczyszyn, David; Mathew, Don

    2014-05-01

    Ischemic stroke in the pediatric population is a rare occurrence, and its possible causes span a wide differential that includes atrial myxomas. Myxomas are friable cardiac tumors that produce "showers" of emboli resulting in transient neurological deficits, cutaneous eruptions, and ophthalmologic deficits. We present an 11-year-old boy with a months-long history of an intermittent spotted "rash" who presented with acute ischemic stroke caused by a left atrial myxoma. We also review clinical features in all 16 other cases of cardiac myxoma causing pediatric stroke reported in the literature. Our case, along with the review of the literature, highlights the fact that myxomas often initially present as stroke with acute hemiplegia and transient cutaneous eruptions due to fragmentation of the tumor. Cardiac myxoma should be considered in any child presenting with ischemic stroke, and transient skin findings may provide an important diagnostic clue prior to onset of neurological symptoms. Copyright © 2014 Elsevier Inc. All rights reserved.

  3. The impact of an educational pain management booklet intervention on postoperative pain control after cardiac surgery.

    PubMed

    Bjørnnes, Ann Kristin; Parry, Monica; Lie, Irene; Fagerland, Morten Wang; Watt-Watson, Judy; Rustøen, Tone; Stubhaug, Audun; Leegaard, Marit

    2017-01-01

    Relevant discharge information about the use of analgesic medication and other strategies may help patients to manage their pain more effectively and prevent postoperative persistent pain. To examine patients' pain characteristics, analgesic intake and the impact of an educational pain management booklet intervention on postoperative pain control after cardiac surgery. Concerns about pain and pain medication prior to surgery will also be described. From March 2012 to September 2013, 416 participants (23% women) were consecutively enrolled in a randomized controlled trial. The intervention group received usual care plus an educational booklet at discharge with supportive telephone follow-up on postoperative day 10, and the control group received only usual care. The primary outcome was worst pain intensity (The Brief Pain Inventory - Short Form). Data about pain characteristics and analgesic use were collected at 2 weeks and at 1, 3, 6 and 12 months post-surgery. General linear mixed models were used to determine between-group differences over time. Twenty-nine percent of participants reported surgically related pain at rest and 9% reported moderate to severe pain at 12 months post-surgery. Many participants had concerns about pain and pain medication, and analgesic intake was insufficient post-discharge. No statistically significant differences between the groups were observed in terms of the outcome measures following surgery. Postoperative pain and inadequate analgesic use were problems for many participants regardless of group allocation, and the current intervention did not reduce worst pain intensity compared with control. Further examination of supportive follow-up monitoring and/or self-management strategies post-discharge is required.

  4. Measurements in Pediatric Patients with Cardiomyopathies: Comparison of Cardiac Magnetic Resonance Imaging and Echocardiography.

    PubMed

    Zhang, Yuting; He, Ling; Cai, Jinhua; Lv, Tiewei; Yi, Qijian; Xu, Yang; Liu, Lingjuan; Zhu, Jing; Tian, Jie

    2015-01-01

    Cardiomyopathies are common cardiovascular diseases in children. Cardiac magnetic resonance imaging (cMRI) and echocardiography (Echo) are routinely applied in the detection and diagnosis of pediatric cardiomyopathies. In this study, we compared and explored the correlation between these two measurements in pediatric patients with various cardiomyopathies. A total of 53 pediatric patients with cardiomyopathy hospitalized during the recent 3 years in our hospital were analyzed. All of them and 22 normal controls were assessed by both cMRI and Echo. Cardiac function of the patients was graded according to the New York Heart Association functional classification. The cardiac function indexes measured with both cMRI and Echo included left-ventricular (LV) end-diastolic volume (EDV), end-systolic volume, ejection fraction and fractional shortening. These parameters were somehow lower in cMRI measurements than in Echo measurements. The index of diastolic function, such as peak filling rate (PFR) measured with cMRI, had a good correlation with the clinical cardiac functional score, while the index of the diastolic function (early/atrial filling ratio and isovolumic relaxation time) measured with Echo was not well correlated with the clinical cardiac function score. Significant systolic dysfunction was detected by cMRI in 34 patients with dilated cardiomyopathy, LV noncompaction or endocardial fibroelastosis. Significant diastolic dysfunction was detected by cMRI in 19 patients with hypertrophic cardiomyopathy or restrictive cardiomyopathy showing an alteration in PFR and EDV. Both cMRI and Echo are of great value in the diagnosis and assessment of cardiac function in pediatric patients with cardiomyopathy. cMRI could accurately display the characteristic morphological changes in the hearts affected with cardiomyopathies, and late gadolinium enhancement on cMRI may reveal myocardial fibrosis, which has obvious advantages over Echo measurements in diagnosis. Furthermore, c

  5. Intraoperative Magnesium Administration Does Not Reduce Postoperative Atrial Fibrillation After Cardiac Surgery

    PubMed Central

    Klinger, Rebecca Y.; Thunberg, Christopher A.; White, William D.; Fontes, Manuel; Waldron, Nathan H.; Piccini, Jonathan P.; Hughes, G. Chad; Podgoreanu, Mihai V.; Stafford-Smith, Mark; Newman, Mark F.; Mathew, Joseph P.

    2015-01-01

    Background Hypomagnesemia has been associated with an increased risk of postoperative atrial fibrillation (POAF). While earlier studies have suggested a beneficial effect of magnesium (Mg) therapy, almost all of these are limited by small sample size and relatively low Mg dose. We hypothesized that high-dose Mg decreases the occurrence of new-onset POAF, and we tested this hypothesis using data from a prospective trial assessing the effect of Mg on cognitive outcomes in cardiac surgical patients. Methods A total of 389 patients undergoing cardiac surgery were enrolled in this double-blind, placebo-controlled trial. Subjects were randomized to receive Mg as a 50 mg/kg bolus immediately after induction of anesthesia followed by another 50 mg/kg as an infusion given over 3 h (total dose 100 mg/kg) or placebo. The effect of Mg therapy on POAF was tested with logistic regression, adjusting for the risk of AF using the Risk Index for Atrial Fibrillation after Cardiac Surgery. Results Among the 363 patients analyzed, after excluding patients with chronic or acute preoperative AF (Placebo: n=177, Mg: n=186), the incidence of new-onset POAF was 42.5% (95% CI: 35 – 50%) in the Mg group compared to 37.9% (95% CI: 31 – 45%) in the placebo group (p=0.40). The 95% confidence interval for this absolute risk difference of 4.6% is −5.5% to 14.7%. The time to onset of POAF was also identical between the groups, and no significant effect of Mg was found in logistic regression analysis adjusting for AF risk (odds ratio 1.09 with 95% CI 0.69 – 1.72, p=0.73). Conclusions High-dose intraoperative Mg therapy did not decrease the incidence of new-onset POAF after cardiac surgery. PMID:26237622

  6. Radiation dose to the pediatric cardiac catheterization and intervention patient.

    PubMed

    Chida, Koichi; Ohno, Tadayuki; Kakizaki, Shuhei; Takegawa, Mika; Yuuki, Hiroko; Nakada, Mitsuru; Takahashi, Shoki; Zuguchi, Masayuki

    2010-11-01

    The radiation dose from cardiac catheterization is particularly relevant when treating children because of their greater radiosensitivity compared with adults. Moreover, cardiac catheterization is being used increasingly for interventional radiology procedures, possibly resulting in higher patient radiation doses. This article reports the radiation doses and related factors, such as fluoroscopy time, for children who underwent cardiac catheterization and children who underwent other interventional radiology procedures. We evaluated 239 consecutive patients who underwent cardiac catheterization (n = 205) or another interventional radiology procedure (n = 34) for which the dose-area product (DAP) was measured. The number of cine runs and fluoroscopic time for each procedure and the body mass index and body weight of each patient were recorded. We also used the double product combined with body weight, which is the weight- fluoroscopic time product. The average DAP ± SD of cardiac catheterization and of an interventional radiology procedure was 1,702.6 ± 2,110.1 cGy × cm² and 2,242.2 ± 2,509.4 cGy × cm², respectively. The average fluoroscopic time ± SD of cardiac catheterization and of an interventional radiology procedure was 24.1 ± 16.8 minutes and 37.2 ± 20.0 minutes. For children who underwent cardiac catheterization and those who underwent an interventional radiology procedure, a strong correlation was seen between the DAP and weight-fluoroscopic time product (cardiac catheterization, r = 0.906; interventional radiology procedure, r = 0.885) and a good correlation was detected between the DAP and weight (r = 0.819 and 0.895, respectively). There was a good correlation between the DAP and weight and between DAP and weight-fluoroscopic time product for children who underwent cardiac catheterization or an interventional radiology procedure. Therefore, body weight is important for determining radiation dose to children undergoing cardiac catheterization or

  7. Cardiac complications in pediatric patients on the ketogenic diet.

    PubMed

    Best, T H; Franz, D N; Gilbert, D L; Nelson, D P; Epstein, M R

    2000-06-27

    Cardiac complications of the ketogenic diet, in the absence of selenium deficiency, have not been reported. Twenty patients on the ketogenic diet at one institution were investigated. Prolonged QT interval (QTc) was found in 3 patients (15%). There was a significant correlation between prolonged QTc and both low serum bicarbonate and high beta-hydroxybutyrate. In addition, three patients had evidence of cardiac chamber enlargement. One patient with severe dilated cardiomyopathy and prolonged QTc normalized when the diet was discontinued.

  8. Early enteral nutrition therapy in congenital cardiac repair postoperatively: A randomized, controlled pilot study

    PubMed Central

    Sahu, Manoj Kumar; Singal, Anuradha; Menon, Ramesh; Singh, Sarvesh Pal; Mohan, Alka; Manral, Mala; Singh, Divya; Devagouru, V.; Talwar, Sachin; Choudhary, Shiv Kumar

    2016-01-01

    Background and Objectives: Adequate nutritional supplementation in infants with cardiac malformations after surgical repair is a challenge. Critically ill infants in the early postoperative period are in a catabolic stress. The mismatch between estimated energy requirement (EER) and the intake in the postoperative period is multifactorial, predisposing them to complications such as immune deficiency, more infection, and growth failure. This study aimed to assess the feasibility and efficacy of enriched breast milk feed on postoperative recovery and growth of infants after open heart surgery. Methodology: Fifty infants <6 months of age were prospectively randomized in the trial for enteral nutrition (EN) postoperatively from day 1 to 10, after obtaining the Institute Ethics Committee's approval. They were equally divided into two groups on the basis of the feed they received: Control group was fed with expressed breast milk (EBM; 0.65 kcal/ml) and intervention group was fed with EBM + energy supplementation/fortification with human milk fortifier (7.5 kcal/2 g)/Simyl medium-chain triglyceride oil (7.8 kcal/ml). Energy need for each infant was calculated as per EER at 90 kcal/kg/day, as the target requirement. The intra- and post-operative variables such as cardiopulmonary bypass and aortic cross-clamp times, ventilation duration, Intensive Care Unit (ICU), and hospital length of stay and mortality were recorded. Anthropometric and hematological parameters and infection control data were recorded in a predesigned pro forma. Data were analyzed using Stata 14.1 software. Results: The duration of mechanical ventilation, length of ICU stay (LOIS), length of hospital stay (LOHS), infection rate, and mortality rate were lower in the intervention group compared to the control group although none of the differences were statistically significant. Infants in control group needed mechanical ventilation for about a day more (i.e., 153.6 ± 149.0 h vs. 123.2 ± 107.0 h; P = 0

  9. Innovation in Pediatric Cardiac Intensive Care: An Exponential Convergence Toward Transformation of Care.

    PubMed

    Maher, Kevin O; Chang, Anthony C; Shin, Andrew; Hunt, Juliette; Wong, Hector R

    2015-10-01

    The word innovation is derived from the Latin noun innovatus, meaning renewal or change. Although companies such as Google and Apple are nearly synonymous with innovation, virtually all sectors in our current lives are imbued with yearn for innovation. This has led to organizational focus on innovative strategies as well as recruitment of chief innovation officers and teams in a myriad of organizations. At times, however, the word innovation seems like an overused cliché, as there are now more than 5,000 books in print with the word "innovation" in the title. More recently, innovation has garnered significant attention in health care. The future of health care is expected to innovate on a large scale in order to deliver sustained value for an overall transformative care. To date, there are no published reports on the state of the art in innovation in pediatric health care and in particular, pediatric cardiac intensive care. This report will address the issue of innovation in pediatric medicine with relevance to cardiac intensive care and delineate possible future directions and strategies in pediatric cardiac intensive care.

  10. Vacuum-assisted closure for mediastinitis after pediatric cardiac surgery.

    PubMed

    Hiramatsu, Takeshi; Okamura, Yoshitaka; Komori, Shigeru; Nishimura, Yoshiharu; Suzuki, Hiroyuki; Takeuchi, Takashi

    2008-10-01

    Two children, aged 1 and 14 years with methicillin-resistant Staphylococcus aureus mediastinitis after pediatric open-heart surgery, were fitted with a vacuum-assisted closure system. Complete healing was achieved in both cases, and primary wound closure could be carried out without an omental flap after 6 and 16 days.

  11. [Pain scale: implementation for patients in the immediate postoperative period of cardiac surgery].

    PubMed

    Keller, Clarissa; Paixão, Adriana; Moraes, Maria Antonieta; Rabelo, Eneida Rejane; Goldmeier, Silvia

    2013-06-01

    A clinical intervention study was developed in a hospital specialized in cardiology in Porto Alegre, RS, Brazil, with the objective of evaluating the implementation of the pain scale in post-operative cardiac surgery patients. It was developed in four steps: pre-test on pain, training lecture for nursing staff, and, reapplication of the pre-test at 30 and 60 days. The test consisted of ten questions weighing one point each. Scores > or =7 were determined to represent satisfactory knowledge in using the pain scale. The sample consisted of 57 nursing professionals. The scores ranged from 6.12 +/- 1.65 in the pre-test to 7.73 +/- 1.05 and 8.18 +/- 0.99 after 30 and 60 days, respectively (p<0.005). Pain intensity was correlated to medication standardized by protocol. The training improved the knowledge of the team and the type of analgesia administered in relation to pain intensity.

  12. Cardiac rehabilitation in a pediatric patient with heart retransplantation. A single case study.

    PubMed

    Chang, K-V; Chiu, H-H; Wang, S-S; Lan, C; Chen, S-Y; Chou, N-K; Wu, M-H; Lai, J-S

    2014-04-01

    Cardiac rehabilitation (CR) after heart transplantation is known to benefit physical capacity in adults, but the advantages of CR on pediatric patients with heart retransplantation remain undetermined. The purpose of the present study was to report the effect of structured CR for a boy receiving heart transplantations twice. Single case study. Inpatient and outpatient rehabilitation department. A pediatric patient underwent heart transplantation due to dilated cardiomyopathy at 13.6 year-old and retransplantation owing to severe cardiac allograft vasculopathy at 16.2 year-old. CR was arranged after both transplantations. Bicycle or treadmill exercises were conducted three times weekly with the intensity adjusted to the ventilatory threshold. Serial cardiopulmonary exercise tests were performed to evaluate the sequential cardiorespiratory function changes using the peak oxygen uptake (VO₂peak) as the primary outcome. The patient had undergone 10 times of exercise tests during rehabilitation. The VO₂peak increased from 12.27 to 15.63 mL·kg-1·min-1 within 6 months after the primary transplantation. However, the VO₂peak dropped intensively after a rejection episode and failed to improve since the development of cardiac allograft vasculopathy. Following retransplantation, the VO₂peak appeared worse initially but increased gradually with rehabilitation. One year subsequent to retransplantation, the VO₂peak reached 17.7 mL·kg-1·min-1 with a 7.22 mL·kg-1·min-1 improvement compared with his baseline value. Structured CR improves aerobic capacity of a pediatric patient with heart retransplantation. CR is safe and beneficial for pediatrics with heart retransplantation. Cardiopulmonary exercise testing can be considered as an adjuvant tool for detecting rejection or cardiac allograft vasculopathy in pediatric heart transplantation recipients.

  13. Correction of ionized plasma magnesium during cardiopulmonary bypass reduces the risk of postoperative cardiac arrhythmia.

    PubMed

    Wilkes, Nicholas J; Mallett, Susan V; Peachey, Tim; Di Salvo, Carmelo; Walesby, Robin

    2002-10-01

    We conducted this randomized controlled trial to determine whether the intraoperative measurement and correction of ionized plasma magnesium can reduce the risk of cardiac arrhythmia after cardiopulmonary bypass. Eighty-five patients presenting for coronary artery bypass grafting were randomly assigned either to the magnesium-corrected group, which received magnesium sulfate on the basis of measured levels of ionized plasma magnesium (n = 43), or to the control group, in which magnesium levels were identified but not corrected (n = 42). Ionized magnesium was determined with an ion-selective electrode with minimal delay, and further samples were taken for laboratory analysis of total plasma magnesium. All patients had Holter electrocardiogram monitoring for 72 h after surgery. Total hypomagnesemia (45 patients; 53% of all patients) was more common than ionized hypomagnesemia (11 patients; 13%) before cardiopulmonary bypass. Both total and ionized magnesium levels declined further during the course of cardiopulmonary bypass in the control group. The incidence of ventricular tachycardia in the first 24 h was less frequent in the magnesium-corrected group (3 patients; 7%) than the control group (12 patients, 30%; P < 0.01). Patients in the magnesium-corrected group were more likely to display continuous sinus rhythm (Lown Grade 0) in the first 24 h (14 patients; 34%) than patients in the control group (2 patients, 5%; P < 0.001). Our results suggest that the intraoperative correction of ionized magnesium is associated with a reduction in postoperative ventricular arrhythmia in cardiac surgical patients. In this study the correction of ionized plasma magnesium during cardiopulmonary bypass was guided by measurements from an ion-selective electrode. This intervention resulted in a reduction in the incidence of postoperative ventricular tachycardia and an increased frequency of continuous sinus rhythm. Ion-selective electrodes constitute a convenient near-patient test

  14. Assessing the generalisability of the pediatric cardiac quality of life inventory in the United Kingdom.

    PubMed

    Wray, Jo; Brown, Kate; Franklin, Rodney; Cassedy, Amy; Marino, Bradley S

    2014-04-01

    To demonstrate the generalisability of the Pediatric Cardiac Quality of Life Inventory in the United Kingdom. Children and adolescents with heart disease were recruited from three tertiary paediatric cardiac centres in the United Kingdom and completed the Pediatric Cardiac Quality of Life Inventory. Item response option variability, total and subscale scores, patterns of correlation, and internal consistency were compared between the three sites. A total of 1537 participants--768 children/adolescents and 769 parents--were evaluated from the three sites. Patterns of item response option variability were similar and acceptable for all samples--child, adolescent, parent of child, and parent of adolescent. Internal consistency was high (0.82-0.96) for all samples from each site, and item-subscale, subscale-subscale, subscale-total, and item-total correlations were moderate to excellent for each centre. Comparisons of patterns of subscale and total score correlations between the three sites revealed no significant differences. Scores on the Pediatric Cardiac Quality of Life Inventory are generalisable in the United Kingdom, supporting the use of this measure for multi-centre studies of health-related quality of life of children and adolescents with heart disease.

  15. Initial Observations of the Effects of Calcium Chloride Infusions in Pediatric Patients with Low Cardiac Output.

    PubMed

    Averin, Konstantin; Villa, Chet; Krawczeski, Catherine D; Pratt, Jesse; King, Eileen; Jefferies, John L; Nelson, David P; Cooper, David S; Ryan, Thomas D; Sawyer, Jaclyn; Towbin, Jeffrey A; Lorts, Angela

    2016-03-01

    Myocardial contractility and relaxation are highly dependent on calcium homeostasis. Immature myocardium, as in pediatric patients, is thought to be more dependent on extracellular calcium for optimal function. For this reason, intravenous calcium chloride infusions may improve myocardial function in the pediatric patient. The objectives of this study were to report the hemodynamic changes seen after administration of continuous calcium chloride to critically ill children. We retrospectively identified pediatric patients (newborn to 17 years old) with hemodynamic instability admitted to the cardiac ICU between May 2011 and May 2012 who received a continuous infusion of calcium chloride. The primary outcome was improvement in cardiac output, assessed by arterial-mixed venous oxygen saturation (A-V) difference. Sixty-eight patients, mean age 0.87 ± 2.67 years, received a total of 116 calcium infusions. Calcium chloride infusions resulted in significant improvements in primary and secondary measures of cardiac output at 2 and 6 h. Six hours after calcium initiation, A-V oxygen saturation difference decreased by 7.4 % (32.6 ± 2.1 to 25.2 ± 2.0 %, p < 0.001), rSO2 increased by 5.5 % (63.1 vs 68.6 %, p < 0.001), and serum lactate decreased by 0.9 mmol/l (3.3 vs 2.4 mmol/l, p < 0.001) with no change in HR (149.1 vs 145.6 bpm p = 0.07). Urine output increased 0.66 ml/kg/h in the 8-h period after calcium initiation when compared to pre-initiation (p = 0.003). Neonates had the strongest evidence of effectiveness with other age groups trending toward significance. Calcium chloride infusions improve markers of cardiac output in a heterogenous group of pediatric patients in a cardiac ICU. Neonates appear to derive the most benefit from utilization of these infusions.

  16. Predictors of Acute Renal Failure During Extracorporeal Membrane Oxygenation in Pediatric Patients After Cardiac Surgery.

    PubMed

    Lv, Lin; Long, Cun; Liu, Jinping; Hei, Feilong; Ji, Bingyang; Yu, Kun; Hu, Qiang; Hu, Jinxiao; Yuan, Yuan; Gao, Guodong

    2016-05-01

    Acute renal failure (ARF) is associated with increased mortality in pediatric extracorporeal membrane oxygenation (ECMO). The aim of this study was to identify predictors of ARF during ECMO in pediatric patients after cardiac surgery. A retrospective study analyzed 42 children (≤15 years) after cardiac surgery requiring venous-arterial ECMO between December 2008 and December 2014 at Fuwai Hospital. ARF was defined as ≥300% rise in serum creatinine (SCr) concentration from baseline or application of dialysis. Multivariate logistic regression was performed to identify the predictors of ARF during ECMO. A total of 42 children (age, interquartile range [IQR], 13.0 [7.2-29.8] months; weight, IQR, 8.5 [6.7-11.0] kg) after cardiac surgery requiring ECMO were included in this study. The total survival rate was 52.4%, and the incidence of ARF was 40.5%. As the result of univariate analysis, ECMO duration, cardiopulmonary resuscitation, maximum free hemoglobin (FHB) during ECMO, lactate level, and mean blood pressure before initiation of ECMO were entered in multiple logistic regression analysis. In multiple logistic regression analysis, FHB during ECMO (OR 1.136, 95% CI 1.023-1.261) and lactate level before initiation of ECMO (OR 1.602, 95% CI 1.025-2.502) were risk factors for ARF during ECMO after pediatric cardiac surgery. There was a linear correlation between maximum SCr and maximum FHB (Pearson's r = 0.535, P = 0.001). Maximum SCr during ECMO has also a linear correlation with lactate level before initiation of ECMO (Pearson's r = 0.342, P = 0.044). Increased FHB during ECMO and high lactate level before initiation of ECMO were risk factors for ARF during ECMO in pediatric patients after cardiac surgery.

  17. Inhaled peppermint oil for postop nausea in patients undergoing cardiac surgery.

    PubMed

    Briggs, Patricia; Hawrylack, Helen; Mooney, Ruth

    2016-07-01

    Postoperative nausea is a common occurrence that is very uncomfortable for patients and may result in complications including pain, strain at the surgical site, aspiration, and possible dehiscence. Antiemetics used to manage the nausea cause many adverse reactions, such as dysrhythmias and/or drowsiness resulting in an unwillingness to ambulate or perform deep-breathing exercises. Previous studies have reported a decrease in nausea following the use of peppermint oil. Researchers obtained informed consent from 123 patients for this study; 34 (28%) of them experienced nausea and were offered a nasal inhaler that contained peppermint oil. The average nausea rating before the use of peppermint oil was 3.29 (SD, 1.0) on a scale of 0 to 5, with 5 being the greatest nausea. Two minutes later, the average nausea rating was 1.44 (SD, 1.3). Using paired t-tests, these differences were found to be statistically significant (P = 0.000). The researchers concluded that peppermint oil inhalation is a viable first-line treatment for nausea in postoperative cardiac surgery patients.

  18. Postoperative surgical site infections in cardiac surgery--an overview of preventive measures.

    PubMed

    Gårdlund, Bengt

    2007-09-01

    Postoperative surgical site infections are a major cause of postoperative morbidity and mortality in cardiac surgery. A surgical site infection occurs when the contaminating pathogens overcome the host defense systems and an infectious process begins. Bacteria may enter the operating site either by direct contamination from the patient's skin or internal organs, through the hands and instruments of the surgical staff or by bacteria-carrying particles that float around in the operating theatre and may land in the wound. The ability to withstand the contaminating bacteria depends on both local and systemic host defense. Successful preventive strategies are multiple and must include: 1) Minimizing the bacterial contamination of the surgical site (skin preparation, operating room ventilation, scrubbing, double gloving, etc.), 2) Minimizing the consequences of virulent contaminating bacteria by antibiotic prophylaxis (adequate dose, sort, timing, duration), 3) Minimizing injury to local host defense (atraumatic surgery, no excessive electrocautery, meticulous hemostasis, etc.), and 4) Optimizing general host defense (nutrition, tobacco smoking, weight loss, etc.). Compliance with these preventive procedures must be enforced through regular reviews of performance. Non-compliance with hygiene routines is often due to ignorance and poor planning. Education of personnel in these issues is a continuous process.

  19. Perioperative management of pediatric patients on mechanical cardiac support.

    PubMed

    Mossad, Emad B; Motta, Pablo; Rossano, Joseph; Hale, Brittani; Morales, David L

    2011-05-01

    The population of children with end-stage heart failure requiring mechanical circulatory support is growing. These children present for diagnostic imaging studies, various interventions and noncardiac surgical procedures that require anesthetic care. This article is a review of the population demographics of children on mechanical cardiac support, the alternative devices available, and the important concepts for safe perioperative management of these patients. The discussion will be limited to devices for short- and long-term cardiac support, excluding extracorporeal membrane oxygenation (ECMO) for respiratory support.

  20. Nomenclature for congenital and paediatric cardiac disease: historical perspectives and The International Pediatric and Congenital Cardiac Code.

    PubMed

    Franklin, Rodney C G; Jacobs, Jeffrey Phillip; Krogmann, Otto N; Béland, Marie J; Aiello, Vera D; Colan, Steven D; Elliott, Martin J; William Gaynor, J; Kurosawa, Hiromi; Maruszewski, Bohdan; Stellin, Giovanni; Tchervenkov, Christo I; Walters Iii, Henry L; Weinberg, Paul; Anderson, Robert H

    2008-12-01

    Clinicians working in the field of congenital and paediatric cardiology have long felt the need for a common diagnostic and therapeutic nomenclature and coding system with which to classify patients of all ages with congenital and acquired cardiac disease. A cohesive and comprehensive system of nomenclature, suitable for setting a global standard for multicentric analysis of outcomes and stratification of risk, has only recently emerged, namely, The International Paediatric and Congenital Cardiac Code. This review, will give an historical perspective on the development of systems of nomenclature in general, and specifically with respect to the diagnosis and treatment of patients with paediatric and congenital cardiac disease. Finally, current and future efforts to merge such systems into the paperless environment of the electronic health or patient record on a global scale are briefly explored. On October 6, 2000, The International Nomenclature Committee for Pediatric and Congenital Heart Disease was established. In January, 2005, the International Nomenclature Committee was constituted in Canada as The International Society for Nomenclature of Paediatric and Congenital Heart Disease. This International Society now has three working groups. The Nomenclature Working Group developed The International Paediatric and Congenital Cardiac Code and will continue to maintain, expand, update, and preserve this International Code. It will also provide ready access to the International Code for the global paediatric and congenital cardiology and cardiac surgery communities, related disciplines, the healthcare industry, and governmental agencies, both electronically and in published form. The Definitions Working Group will write definitions for the terms in the International Paediatric and Congenital Cardiac Code, building on the previously published definitions from the Nomenclature Working Group. The Archiving Working Group, also known as The Congenital Heart Archiving

  1. The effect of nasogastric tube application during cardiac surgery on postoperative nausea and vomiting--a randomized trial.

    PubMed

    Lavi, Ronit; Katznelson, Rita; Cheng, Davy; Minkovich, Leonid; Klein, Andy; Carroll, Jo; Karski, Jacek; Djaiani, George

    2011-02-01

    Postoperative nausea and vomiting (PONV) are significant morbidities following cardiac surgery. The purpose of this study was to determine if application of a nasogastric (NG) tube during cardiac surgery can reduce the prevalence of postoperative PONV. This study was a prospective randomized controlled trial. University tertiary referral center. Two hundred two patients undergoing elective cardiac procedures. Patients were prospectively enrolled and randomized to either receive or not receive an NG tube after induction of anesthesia. Standard anesthetic technique and postoperative care were employed in all patients. Preoperative demographic data, pain score, nausea score and incidence of vomiting were recorded early (0-8 hours) and late (8-16 hours) following extubation. Antiemetic and analgesic medications were compared between the 2 groups. One hundred three patients were randomized to no an NG tube (controls) and 99 received an NG tube as part of their perioperative management. Demographic data and surgical characteristics were similar between the 2 groups. However, the control group had more smokers. Incidence and severity of nausea, pain scores, and analgesic requirements were similar between the 2 groups. Prevalence of vomiting was more frequent in the control group (24%) than in the NG tube group (10%, p = 0.007), and was more frequent in patients who underwent valve and redo procedures. Use of an NG tube during cardiac surgery may reduce the incidence of postoperative vomiting. Copyright © 2011 Elsevier Inc. All rights reserved.

  2. Preoperative Preparation for Cardiac Surgery Facilitates Recovery, Reduces Psychological Distress, and Reduces the Incidence of Acute Postoperative Hypertension.

    ERIC Educational Resources Information Center

    Anderson, Erling A.

    1987-01-01

    Cardiac surgery patients were assigned to information-only, information-plus-coping, or control preoperative preparation groups. Preoperatively, both experimental groups were significantly less anxious than were controls. Both experimental groups increased patients' belief in control over recovery. Postoperatively, experimental patients were less…

  3. Preoperative Preparation for Cardiac Surgery Facilitates Recovery, Reduces Psychological Distress, and Reduces the Incidence of Acute Postoperative Hypertension.

    ERIC Educational Resources Information Center

    Anderson, Erling A.

    1987-01-01

    Cardiac surgery patients were assigned to information-only, information-plus-coping, or control preoperative preparation groups. Preoperatively, both experimental groups were significantly less anxious than were controls. Both experimental groups increased patients' belief in control over recovery. Postoperatively, experimental patients were less…

  4. Time series analysis as input for clinical predictive modeling: modeling cardiac arrest in a pediatric ICU.

    PubMed

    Kennedy, Curtis E; Turley, James P

    2011-10-24

    Thousands of children experience cardiac arrest events every year in pediatric intensive care units. Most of these children die. Cardiac arrest prediction tools are used as part of medical emergency team evaluations to identify patients in standard hospital beds that are at high risk for cardiac arrest. There are no models to predict cardiac arrest in pediatric intensive care units though, where the risk of an arrest is 10 times higher than for standard hospital beds. Current tools are based on a multivariable approach that does not characterize deterioration, which often precedes cardiac arrests. Characterizing deterioration requires a time series approach. The purpose of this study is to propose a method that will allow for time series data to be used in clinical prediction models. Successful implementation of these methods has the potential to bring arrest prediction to the pediatric intensive care environment, possibly allowing for interventions that can save lives and prevent disabilities. We reviewed prediction models from nonclinical domains that employ time series data, and identified the steps that are necessary for building predictive models using time series clinical data. We illustrate the method by applying it to the specific case of building a predictive model for cardiac arrest in a pediatric intensive care unit. Time course analysis studies from genomic analysis provided a modeling template that was compatible with the steps required to develop a model from clinical time series data. The steps include: 1) selecting candidate variables; 2) specifying measurement parameters; 3) defining data format; 4) defining time window duration and resolution; 5) calculating latent variables for candidate variables not directly measured; 6) calculating time series features as latent variables; 7) creating data subsets to measure model performance effects attributable to various classes of candidate variables; 8) reducing the number of candidate features; 9

  5. Time series analysis as input for clinical predictive modeling: Modeling cardiac arrest in a pediatric ICU

    PubMed Central

    2011-01-01

    Background Thousands of children experience cardiac arrest events every year in pediatric intensive care units. Most of these children die. Cardiac arrest prediction tools are used as part of medical emergency team evaluations to identify patients in standard hospital beds that are at high risk for cardiac arrest. There are no models to predict cardiac arrest in pediatric intensive care units though, where the risk of an arrest is 10 times higher than for standard hospital beds. Current tools are based on a multivariable approach that does not characterize deterioration, which often precedes cardiac arrests. Characterizing deterioration requires a time series approach. The purpose of this study is to propose a method that will allow for time series data to be used in clinical prediction models. Successful implementation of these methods has the potential to bring arrest prediction to the pediatric intensive care environment, possibly allowing for interventions that can save lives and prevent disabilities. Methods We reviewed prediction models from nonclinical domains that employ time series data, and identified the steps that are necessary for building predictive models using time series clinical data. We illustrate the method by applying it to the specific case of building a predictive model for cardiac arrest in a pediatric intensive care unit. Results Time course analysis studies from genomic analysis provided a modeling template that was compatible with the steps required to develop a model from clinical time series data. The steps include: 1) selecting candidate variables; 2) specifying measurement parameters; 3) defining data format; 4) defining time window duration and resolution; 5) calculating latent variables for candidate variables not directly measured; 6) calculating time series features as latent variables; 7) creating data subsets to measure model performance effects attributable to various classes of candidate variables; 8) reducing the number of

  6. Associations Between Pediatric Choledochal Cysts, Biliary Atresia, and Congenital Cardiac Anomalies

    PubMed Central

    Murphy, Andrew J.; Axt, Jason R.; Lovvorn, Harold N.

    2012-01-01

    Background In our institutional experience treating pediatric choledochal cysts over the last 12 years, we noted 7/32 patients (21.9%) had comorbid congenital cardiac anomalies. This association has not been previously described other than in isolated case reports. We aimed to quantify this association on a national level. Materials and Methods We queried the 2009 Healthcare Cost and Utilization Project Kids' Inpatient Database. Patients with a diagnosis of choledochal cyst (ICD-9-CM 75169, 75162, 75160) or biliary atresia (75161) were identified. Cardiac anomalies were defined using the Clinical Classification Software code (CCS 213). Comorbid choledochal cysts or biliary atresia and congenital cardiac anomalies were quantified in both infant (<12 mos) and child (1–18 yrs) subpopulations. Results Of 1,646 estimated discharges for patients with choledochal cysts, 506 (30.7%) were for patients who also had congenital cardiac anomalies, compared to 2.6% in the general hospitalized population (χ2, p<0.0001). The frequency of congenital cardiac anomalies was lower in 1,973 hospitalizations for biliary atresia (13.8%) than in those for patients with choledochal cysts (χ2, p<0.0001). Cardiac anomalies were detected in 44.9% of choledochal cyst hospitalizations for infants <12 months (vs. 3.44% general hospitalized population; χ2, p<0.0001), but in 6.9% of for children ages 1–18 yrs (vs. 1.3% general hospitalized population; χ2, p<0.0001). Conclusions A strong association was observed between pediatric choledochal cysts and congenital cardiac anomalies that more commonly manifests in infancy. When choledochal cysts are diagnosed either prenatally or in infancy, we suggest echocardiographic screening for cardiac anomalies, which may impact timing of surgery and anesthetic planning. PMID:22572617

  7. Alkaline Phosphatase: A Biomarker of Cardiac Function in Pediatric Patients.

    PubMed

    Makil, Elizabeth S; Tang, Xinyu; Frazier, Elizabeth A; Collins, R Thomas

    2017-02-09

    Myocardial dysfunction and heart failure are common in pediatric patients with congenital and acquired heart disease. Alkaline phosphatase (AP) has been suggested as a biomarker for myocardial dysfunction after Fontan operation. We hypothesized that pediatric patients with myocardial dysfunction requiring orthotopic heart transplant (OHT) have diminished AP compared to normal. A retrospective review was performed in all patients who underwent OHT at Arkansas Children's Hospital between January 2007 and October 2012. Anatomic diagnoses, therapeutic interventions, and ventricular ejection fraction (EF) were recorded. Z scores for AP levels in the study group were determined by comparing the observed AP levels to age- and gender-matched normative values. T tests were performed to compare the mean AP Z score prior to and after OHT. p values <0.05 were considered statistically significant. During the study period, 124 OHTs were performed. Complete study data were available and analyzed from 71/124 patients (mean age at OHT 3.9 years; 51% female). The mean AP Z score was significantly lower in the study group prior to OHT compared to normal (p < 0.0001). The initiation of ACE inhibitor therapy prior to OHT was associated with a significant increase in AP and the ventricular EF (p < 0.001 for both). Treatment with milrinone was associated with an increase in EF. AP is significantly lower in pediatric patients with myocardial dysfunction prior to OHT compared to normal. AP increases significantly after the initiation of therapies to improve myocardial function. Diminished AP is an indicator of myocardial dysfunction in pediatric patients.

  8. Prevalence of post-operative morbidity risk factors following cardiac surgery in patients with chronic viral hepatitis: a retrospective study.

    PubMed

    Hsieh, W C; Chen, P C; George, G; Tinica, G; Corciova, F-C

    2015-01-01

    Current cardiac risk assessments such as EuroSCORE II and the STS-Score do not take liver dysfunction into account. The purpose of this study was to evaluate the prevalence and post-operative morbidity risk factors following cardiac surgery of patients with chronic viral hepatitis. The study group consisted of 105 patients with documented chronic viral hepatitis who were subject to elective cardiac surgery from 2001 to 2012. Subjects were evaluated for pre-operative liver dysfunction according to the MELD score. The average MELD score of the study group was 10.00 ± 6.00. The average EuroSCORE ii of the study group was 2.07% ± 1.62%. The primary post-operative complication was cardiac complications (n=57, 54.3%). Analysis showed significant differences in meld score, bilirubin and smoking. Multivariate logistic regression analysis showed that the variables entering into the model included such risk factors with a significant or near significant (p < 0.2) influence on hospital morbidity and consisted in valve vs. coronary artery disease, valve/cad, aortic valve replacement vs. Coronary artery bypass graft, and bilirubin (mg/dl). it is vital that liver dysfunction is added to the risk models which are currently utilized to predict the post-operative morbidity of cardiac surgery patients.

  9. Intraoperative hemodynamic factors predicting early postoperative renal function in pediatric kidney transplantation.

    PubMed

    Michelet, Daphné; Brasher, Christopher; Marsac, Lucile; Zanoun, Nabil; Assefi, Mona; Elghoneimi, Alaa; Dauger, Stephane; Dahmani, Souhayl

    2017-09-01

    The anesthetic management of kidney transplantation in children remains somewhat empirical. The goal of the present study was to investigate intraoperative hemodynamic factors affecting posttransplantation kidney function. We performed a retrospective analysis of data from patients undergoing kidney transplantation in our pediatric teaching hospital from 2000 to 2014. Data collected included: donor and recipient demographic data, recipient comorbidities, fluids administered intraoperatively, and intraoperative blood pressure and central venous pressure. The main outcome of the study was the creatinine clearance at day 1 corrected to a body surface area of 1.73 m². Analysis was performed using Classification Tree Analysis with 10-fold cross-validation. One hundred and two patients were included. The following predictors of increased postoperative creatinine clearance at day 1 were identified: decreasing recipient weight, mean blood pressure-to-weight ratio 10 minutes after reperfusion, reduced cold ischemia duration, and increased intraoperative albumin infusion. Increased creatinine clearance was observed when mean blood pressure-to-weight ratio 10 minutes after reperfusion was ≥4.3 in patients weighing 13-21 kg and ≥2.5 in those ≥22 kg. Overall, the model explained 64% (and at cross-validation 60%) of creatinine clearance variability at day 1. Intraoperative hemodynamics during kidney transplantation should be optimized in order to increase mean blood pressure according to values indicated by our analyses. Cold ischemia duration should be shortened as far as possible. © 2017 John Wiley & Sons Ltd.

  10. The ALARA concept in pediatric cardiac catheterization: techniques and tactics for managing radiation dose.

    PubMed

    Justino, Henri

    2006-09-01

    The cardiac catheterization laboratory plays an important role in the management of children with congenital heart disease by not only enabling diagnosis but, in many cases, providing definitive therapy. The goal of the ALARA (As Low as Reasonably Achievable) concept as it applies to cardiac catheterization is to provide maximal diagnostic and therapeutic benefit while requiring the lowest possible radiation dose. A number of specific challenges unique to the setting of pediatric cardiac catheterization, such as higher heart rates, smaller cardiovascular structures, smaller body size, and wider variety of unusual anatomic variants with the potential need for relatively lengthy and complex studies, result in relatively high radiation doses (to the patient and, consequently, to laboratory personnel). In addition, the improved survival of patients with complex anatomy (e.g., palliated single ventricle anatomies) implies that many such children with chronic cardiac disease require frequent catheterizations within the first few years of life. These factors, coupled with the increased radiosensitivity of children and a longer lifespan ahead of them in which to possibly develop radiation-related sequelae, converge to create potentially ominous consequences. Attention to basic rules of radiation safety is, therefore, of tremendous importance in the pediatric cardiac catheterization laboratory. This review focuses on the importance of adequate planning of the study, optimizing image formation, management of fluoroscopy and cine angiography parameters, and the use of certain equipment features that might allow the cardiologist to lower the radiation dose without sacrificing image quality.

  11. Osteosarcoma Metastases With Direct Cardiac Invasion: A Case Report and Review of the Pediatric Literature.

    PubMed

    Hartemayer, Robert; Kuo, Christopher; Kent, Paul

    2017-04-01

    Metastatic osteosarcoma with direct cardiac involvement is an exceptionally rare finding, with only 63 total reported cases in the English literature over the past 123 years. Although the precise incidence is unknown, we estimate that direct cardiac involvement currently occurs in <2% of metastatic osteosarcoma cases. We also find that before the adoption of adjuvant chemotherapy as a standard of care therapy for osteosarcoma, metastatic osteosarcoma to the heart was much more common than it is today, as cardiac involvement occurred in ∼20% of cases of metastatic osteosarcoma before the 1980s. This suggests that adjuvant chemotherapy has not only improved the overall prognosis of osteosarcoma, but also altered the metastatic pattern of disease. In this paper we present the case of an 11-year-old boy with metastatic osteosarcoma to the cardiac interventricular septum, as well as review 20 other previously reported pediatric cases of metastatic osteosarcoma to the heart. We also analyzed the cardiac surgical outcomes for 11 pediatric patients with metastatic osteosarcoma to the heart. The median disease-free survival time was 12 months, demonstrating that metastatic osteosarcoma to the heart is currently a rare occurrence with a poor prognosis.

  12. Pediatric cardiac surgery in low- and middle-income countries or emerging economies: a continuing challenge.

    PubMed

    Nguyen, Nguyenvu; Pezzella, A Thomas

    2015-04-01

    A number of recent publications, addresses, seminars, and conferences have addressed the global backlog and increasing incidence of both congenital and acquired cardiac diseases in children, with reference to early and delayed recognition, late referral, availability of and access to services, costs, risks, databases, and early and long-term results and follow-up. A variety of proposals, recommendations, and projects have been outlined and documented. The ultimate goal of these endeavors is to increase the quality and quantity of pediatric cardiac care and surgery worldwide and particularly in underserved areas. A contemporary review of past and present initiatives is presented with a subsequent focus on the more challenging areas.

  13. An initial experience with a digital drainage system during the postoperative period of pediatric thoracic surgery.

    PubMed

    Costa, Altair da Silva; Bachichi, Thiago; Holanda, Caio; Rizzo, Luiz Augusto Lucas Martins De

    2016-01-01

    To report an initial experience with a digital drainage system during the postoperative period of pediatric thoracic surgery. This was a prospective observational study involving consecutive patients, ≤ 14 years of age, treated at a pediatric thoracic surgery outpatient clinic, for whom pulmonary resection (lobectomy or segmentectomy via muscle-sparing thoracotomy) was indicated. The parameters evaluated were air leak (as quantified with the digital system), biosafety, duration of drainage, length of hospital stay, and complications. The digital system was used in 11 children (mean age, 5.9 ± 3.3 years). The mean length of hospital stay was 4.9 ± 2.6 days, the mean duration of drainage was 2.5 ± 0.7 days, and the mean drainage volume was 270.4 ± 166.7 mL. The mean maximum air leak flow was 92.78 ± 95.83 mL/min (range, 18-338 mL/min). Two patients developed postoperative complications (atelectasis and pneumonia, respectively). The use of this digital system facilitated the decision-making process during the postoperative period, reducing the risk of errors in the interpretation and management of air leaks. Relatar a experiência inicial com um sistema de drenagem digital no pós-operatório de cirurgia torácica pediátrica. Estudo observacional e prospectivo envolvendo pacientes consecutivos do ambulatório de cirurgia torácica pediátrica da instituição, com idade até 14 anos, e com indicação de ressecção pulmonar (lobectomia e/ou segmentectomia através de toracotomia poupadora muscular). Os parâmetros avaliados foram perda aérea (quantificada com o sistema digital), biossegurança, tempo de drenagem, tempo de internação e complicações. O sistema digital foi utilizado em 11 crianças, com média de idade de 5,9 ± 3,3 anos. A média do tempo de internação foi de 4,9 ± 2,6 dias, a de tempo de drenagem foi de 2,5 ± 0,7 dias, e a de volume de drenagem foi de 270,4 ± 166,7 ml. A média da perda aérea máxima foi de 92,78 ± 95,83 ml

  14. Washing red blood cells and platelets transfused in cardiac surgery reduces post-operative inflammation and number of transfusions: Results of a prospective, randomized, controlled clinical trial

    PubMed Central

    Cholette, Jill M; Henrichs, Kelly F; Alfieris, George M; Powers, Karen S.; Phipps, Richard; Spinelli, Sherry L.; Swartz, Michael; Gensini, Francisco; Daugherty, L. Eugene; Nazarian, Emily; Rubenstein, Jeffrey S.; Sweeney, Dawn; Eaton, Michael; Lerner, Norma B; Blumberg, Neil

    2013-01-01

    Objective Children undergoing cardiac surgery with cardiopulmonary bypass (CPB) are susceptible to additional inflammatory and immunogenic insults from blood transfusions. We hypothesize that washing red blood cells (RBC) and platelets transfused to these patients will reduce post-operative transfusion-related immune modulation and inflammation. Design Prospective randomized controlled clinical trial. Setting University hospital pediatric cardiac intensive care unit. Patients Children from birth to 17 years old undergoing cardiac surgery with CPB. Interventions Children were randomized to an unwashed or washed RBC and platelet transfusion protocol for their surgery and postoperative care. All blood was leukoreduced, irradiated, and ABO identical. Plasma was obtained for laboratory analysis: pre-op, immediately, six and 12 hours after CPB. Primary outcome was the 12-hour post-CPB interleukin (IL)-6: IL-10 ratio. Secondary measures were IL levels, C-reactive protein (CRP), and clinical outcomes. Measurements and main results 162 subjects were studied, 81 per group. 34 subjects (17 per group) did not receive any blood transfusions. Storage duration of blood products was similar between groups. Among transfused subjects, the 12-hour IL ratio was significantly lower in the washed group (3.8 v. 4.8; p=0.04) secondary to lower IL-6 levels (post-CPB: 65 v.100 pg/ml; p = 0.06; 6 hour: 89 v.152 pg/ml; p = 0.02; 12-hour: 84 v.122 pg/ml; p = 0.09). Post-operative CRP was lower in subjects receiving washed blood (38 v. 43 mg/L; p = 0.03). There was a numerical, but not statistically significant decrease in total blood product transfusions (203 v. 260) and mortality (2 v. 6 deaths) in the washed group compared to the unwashed group. Conclusions Washed blood transfusions in cardiac surgery reduced inflammatory biomarkers, number of transfusions, donor exposures, and were associated with a non-significant trend towards reduced mortality. A larger study powered to test for clinical

  15. Results of emergency postoperative re-angiography after cardiac surgery procedures.

    PubMed

    Gaudino, Mario; Nesta, Marialisa; Burzotta, Francesco; Trani, Carlo; Coluccia, Valentina; Crea, Filippo; Massetti, Massimo

    2015-05-01

    The purpose of this study was to evaluate the diagnostic and therapeutic role of emergency coronary angiography (ECA) in the setting of acute ischemic or hemodynamic instability after cardiac surgery. Between January 2005 and September 2014 we prospectively collected data from a consecutive cohort of 5,275 patients who underwent cardiac surgery. Patients who underwent ECA due to new ST-segment changes on electrocardiogram (ECG), ventricular arrhythmias, cardiac arrest or hemodynamic collapse, new changes in regional wall motion, or any other relevant suspect of myocardial ischemia during postoperative intensive care unit stay were included. Forty patients (0.7% of the overall population) were enrolled. Nineteen patients (47.5%) received isolated coronary surgery, 21 (52.5%) underwent valve or aortic or combined operations. The most common indications to ECA were new ECG or echo signs of acute ischemia (62.5%). The mean time from primary operation to ECA was 51 hours (27 minutes to 9 days). Graft failure was found in 17 cases (42.5%), native coronary artery occlusion in 7 (20%), and coronary spasm in 5 (12.5%). No pathologic alterations were found in 7 cases (17.5%). Three patients (7.5%) underwent reoperation (group 1), 15 (37.5%) underwent percutaneous interventions (PCI) (group 2), and 22 (55%) were managed conservatively (group 3). In-hospital mortality was 100% in group 1, 6% in group 2, and 0% in group 3; 93% of the patients who underwent PCI had complete resolution of the ischemic or hemodynamic problems. No complications related to angiography occurred. Kaplan-Meier survival curves differed significantly according to the post-angiography management. At multivariate analysis combined surgery and the strategy of treatment were independent predictors of long-term mortality. Emergency coronary angiography is safe and allows diagnosis and resolution of the instability in the great majority of cases. An ECA should be the first-line measure in case of acute

  16. Duration of red blood cell storage and outcomes in pediatric cardiac surgery: an association found for pump prime blood.

    PubMed

    Ranucci, Marco; Carlucci, Concetta; Isgrò, Giuseppe; Boncilli, Alessandra; De Benedetti, Donatella; De la Torre, Teresa; Brozzi, Simonetta; Frigiola, Alessandro

    2009-01-01

    Cardiac surgery using cardiopulmonary bypass in newborns, infants and small children often requires intraoperative red blood cell transfusions to prime the circuit and oxygenator and to replace blood lost during surgery. The purpose of this study was to investigate the influence of red blood cell storage time prior to transfusion on postoperative morbidity in pediatric cardiac operations. One hundred ninety-two consecutive children aged five years or less who underwent cardiac operations using cardiopulmonary bypass and who received red blood cells for priming the cardiopulmonary bypass circuit comprised the blood-prime group. Forty-seven patients receiving red blood cell transfusions after cardiopulmonary bypass were separately analyzed. Patients in the blood-prime group were divided into two groups based on the duration of storage of the red blood cells they received. The newer blood group included patients who received only red blood cells stored for less than or equal to four days and the older blood group included patients who received red blood cells stored for more than four days. Patients in the newer blood group had a significantly lower rate of pulmonary complications (3.5% versus 14.4%; P = 0.011) as well as a lower rate of acute renal failure (0.8% versus 5.2%; P = 0.154) than patients in the older blood group. Major complications (calculated as a composite score based on pulmonary, neurological, and gastroenterological complications, sepsis and acute renal failure) were found in 6.9% of the patients receiving newer blood and 17.1% of the patients receiving older blood (P = 0.027). After adjusting for other possible confounding variables, red blood cell storage time remained an independent predictor of major morbidity. The same association was not found for patients receiving red blood cell transfusions after cardiopulmonary bypass. The storage time of the red blood cells used for priming the cardiopulmonary bypass circuit in cardiac operations on

  17. Pediatric Emergency Appendectomy and 30-Day Postoperative Outcomes in District General Hospitals and Specialist Pediatric Surgical Centers in England, April 2001 to March 2012: Retrospective Cohort Study.

    PubMed

    Giuliani, Stefano; Cecil, Elizabeth V; Apelt, Nadja; Sharland, Michael; Saxena, Sonia

    2016-01-01

    To compare trends in pediatric emergency appendectomy and adverse surgical outcomes between district general hospitals (DGHs) and specialist pediatric centers (SPCs). In the past decades in England, a significant reduction in the number of children operated by adult general surgeons has raised concerns about their surgical outcomes compared with specialist pediatric surgeons. Using Hospital Episode Statistics, we analyzed patient-level data between April 2001 and March 2012. Main inclusion criteria were children younger than 16 years admitted to NHS-England hospitals for an emergency appendectomy. Main outcomes were annual age-sex adjusted appendectomy rates and postoperative risk of readmission, complication, and reintervention. A total of 83,679 emergency pediatric appendectomies were performed in 21 SPCs and 183 DGHs in England. SPCs performed only 18% of these operations (15,002). Annual age-sex standardized appendectomy rates fell from 87 to 68 per 100,000 population at an estimated 2% (rate ratio, 0.98) fall per annum. This was accompanied by a national annual increased risk of negative appendectomy, complication, reintervention, and readmission (adjusted odds ratio: 1.02, 1.03, 1.04, and 1.06, respectively). Children who had appendectomies in DGHs had 28% more negative appendectomies, 11% more complications, and 11% more readmissions than those in SPCs. Postoperative length of stay was double in SPCs compared with DGHs (median, 4 vs 2 days). Major reductions in the number of pediatric emergency appendectomies in England over the past decade were associated with an overall increase in adverse surgical outcomes. Children operated in DGHs have more reinterventions, complications, and negative appendectomy rates than those operated in SPCs.

  18. Provision of Transition Education and Referral Patterns from Pediatric Cardiology to Adult Cardiac Care.

    PubMed

    Harbison, Anna L; Grady, Stafford; Chi, Kevin; Fernandes, Susan M

    2016-02-01

    ACC/AHA guidelines recommend a structured preparation for and transfer to adult-oriented cardiac care for adult survivors of pediatric onset heart disease (POHD). Given this, we sought to describe the transition and transfer practices for a cohort of young adults with POHD and to determine factors associated with successful transfer to adult-oriented cardiac care. We performed a single-center, retrospective chart review on patients ≥18 years of age, with POHD likely to require lifelong cardiac care, who were seen in outpatient pediatric cardiology (PC) between 2008 and 2011. Successful transfer was defined as the subsequent attendance at adult cardiology (AC) within 2 years of PC visit. We identified 118 patients who met study criteria. Mean age 22.4 ± 2.0 years, 59 % male, 64 % white and 40 % Hispanic. Mean transition education topics noted was 3.3 ± 1.8 out of 20 and covered the underlying cardiac disease (89 %), follow-up and current medications (56 %) and exercise limitations (34 %). Recommendations for follow-up were AC (57 %) and PC (33 %). Of those told to transfer to AC, 79 % successfully transferred. Characteristics of successful transfer included: prior cardiac surgery (p = 0.008), cardiac medication use (p = 0.006) and frequency of follow-up ≤1 year (p = 0.037). One-quarter of all subjects did not follow-up within at least 2 years. Despite published guidelines, transition education appears lacking and the approach to transfer to adult cardiac care is not consistent. Given the increased risk of morbidity and mortality in this patient population, standardization of transition education and transfer processes appear warranted.

  19. Effect of prehospital advanced airway management for pediatric out-of-hospital cardiac arrest.

    PubMed

    Ohashi-Fukuda, Naoko; Fukuda, Tatsuma; Doi, Kent; Morimura, Naoto

    2017-05-01

    Respiratory care may be important in pediatric out-of-hospital cardiac arrest (OHCA) due to the asphyxial nature of the majority of events. However, evidence of the effect of prehospital advanced airway management (AAM) for pediatric OHCA is scarce. This was a nationwide population-based study of pediatric OHCA in Japan from 2011 to 2012 based on data from the All-Japan Utstein Registry. We included pediatric OHCA patients aged between 1 and 17 years old. The primary outcome was one-month neurologically favorable survival defined as a Glasgow-Pittsburgh cerebral performance category (CPC) score of 1-2 (corresponding to a Pediatric CPC score of 1-3). A total of 2157 patients were included in the final cohort; 365 received AAM and 1792 received bag-valve-mask (BVM) ventilation only. Among the 2157 patients, 213 (9.9%) survived with favorable neurological outcomes (CPC of 1-2) one month after OHCA. There were no significant differences in neurologically favorable survival between the AAM and BVM groups after adjusting for potential confounders, although there was a tendency favoring BVM ventilation: propensity score matching, OR 0.74 (95%CI 0.35-1.59), and multivariable logistic regression modeling, ORadjusted 0.55 (95%CI 0.24-1.14). Subgroup analyses demonstrated that there were no subgroups in which AAM was associated with neurologically favorable survival, including the non-cardiac (primarily asphyxial) etiology group. In pediatric OHCA, prehospital AAM was not associated with an increased chance of neurologically favorable survival compared with BVM-only ventilation. However, careful consideration is required to interpret the findings, as there may be unmeasured residual confounders and selection bias. Copyright © 2017 Elsevier B.V. All rights reserved.

  20. Mediastinitis in pediatric cardiac surgery: Prevention, diagnosis and treatment

    PubMed Central

    Durandy, Yves

    2010-01-01

    In spite of advances in the management of mediastinitis following sternotomy, mediastinitis is still associated with significant morbidity. The prognosis is much better in pediatric surgery compared to adult surgery, but the prolonged hospital stays with intravenous therapy and frequent required dressing changes that occur with several therapeutic approaches are poorly tolerated. Prevention includes nasal decontamination, skin preparation, antibioprophylaxis and air filtration in the operating theater. The expertise of the surgical team is an additional factor that is difficult to assess precisely. Diagnosis is often very simple, being made on the basis of a septic state with wound modification, while retrosternal puncture and CT scan are rarely useful. Treatment of mediastinitis following sternotomy is always a combination of surgical debridement and antibiotic therapy. Continued use of numerous surgical techniques demonstrates that there is no consensus and the best treatment has yet to be determined. However, we suggest that a primary sternal closure is the best surgical option for pediatric patients. We propose a simple technique with high-vacuum Redon’s catheter drainage that allows early mobilization and short term antibiotherapy, which thus decreases physiological and psychological trauma for patients and families. We have demonstrated the efficiency of this technique, which is also cost-effective by decreasing intensive care and hospital stay durations, in a large group of patients. PMID:21179306

  1. The Kidney in Critical Cardiac Disease: Proceedings From the 10th International Conference of the Pediatric Cardiac Intensive Care Society.

    PubMed

    Cooper, David S; Basu, Rajit K; Price, Jack F; Goldstein, Stuart L; Krawczeski, Catherine D

    2016-03-01

    The field of cardiac intensive care continues to advance in tandem with congenital heart surgery. The focus of intensive care unit care has now shifted to that of morbidity reduction and eventual elimination. Acute kidney injury (AKI) after cardiac surgery is associated with adverse outcomes, including prolonged intensive care and hospital stays, diminished quality of life, and increased long-term mortality. Acute kidney injury occurs frequently, complicating the care of both postoperative patients and those with heart failure. Patients who become fluid overloaded and/or require dialysis are at high risk of mortality, but even minor degrees of AKI portend a significant increase in mortality and morbidity. Clinicians continue to seek methods of early diagnosis and risk stratification of AKI to prevent its adverse sequelae. Previous conventional wisdom that survivors of AKI fully recover renal function without subsequent consequences may be flawed.

  2. Anesthesia and Databases: Pediatric Cardiac Disease as a Role Model.

    PubMed

    Vener, David F; Pasquali, Sara K; Mossad, Emad B

    2017-02-01

    Large data sets have now become ubiquitous in clinical medicine; they are particularly useful in high-acuity, low-volume conditions such as congenital heart disease where data must be collected from many centers. These data fall into 2 categories: administrative data arising from hospital admissions and charges and clinical data relating to specific diseases or procedures. In congenital cardiac diseases, there are now over a dozen of these data sets or registries focusing on various elements of patient care. Using probabilistic statistic matching, it is possible to marry administrative and clinical data post hoc using common elements to determine valuable information about care patterns, outcomes, and costs. These data sets can also be used in a collaborative fashion between institutions to drive quality improvement (QI). Because these data may include protected health information (PHI), care must be taken to adhere to federal guidelines on their use. A fundamental principle of large data management is the use of a common language and definition (nomenclature) to be effective. In addition, research derived from these information sources must be appropriately balanced to ensure that risk adjustments for preoperative and surgical factors are taken into consideration during the analysis. Care of patients with cardiac disease both in the United States and abroad consistently shows wide variability in mortality, morbidity, and costs, and there has been a tremendous amount of discussion about the benefits of regionalization of care based on center volume and outcome measurements. In the absence of regionalization, collaborative learning techniques have consistently been shown to minimize this variability and improve care at all centers, but before changes can be made it is necessary to accurately measure accurately current patient outcomes. Outcomes measurement generally falls under hospital-based QI initiatives, but more detailed analysis and research require

  3. Prophylactic furosemide infusion decreasing early major postoperative renal dysfunction in on-pump adult cardiac surgery: a randomized clinical trial

    PubMed Central

    Fakhari, Solmaz; Bavil, Fariba Mirzaei; Bilehjani, Eissa; Abolhasani, Sona; Mirinazhad, Moussa; Naghipour, Bahman

    2017-01-01

    Introduction Acute renal dysfunction is a common complication of cardiac surgery. Furosemide is used in prevention, or treatment, of acute renal dysfunction. This study was conducted to evaluate the protective effects of intra- and early postoperative furosemide infusion on preventing acute renal dysfunction in elective adult cardiac surgery. Methods Eighty-one patients, candidates of elective cardiac surgery, were enrolled in this study in either the furosemide (n=41) or placebo (n=40) group. Furosemide (2 mg/h) or 0.9% saline was administered and continued up to 12 hours postoperatively. We measured serum creatinine (Scr) at preoperative and on the second and fifth postoperative days. Then calculated estimated glomerular filtration rate (eGFR) at these times. An increase in Scr of >0.5 mg/dL and/or >25%–50%, compared to preoperative values, was considered as acute kidney injury (AKI). In contrast, an increase in Scr by >50% and/or the need for hemodialysis was regarded as acute renal failure (ARF). At the end we compared the AKI or ARF incidence between the two groups. Results On the second and fifth postoperative days, Scr was lower, and the eGFR was higher in the furosemide group. AKI incidence was similar in the two groups (11 vs 12 cases; P-value 0.622); however, ARF rate was lower in furosemide group (1 vs 6 cases; P-value 0.044). During the study period, Scr was more stable in the furosemide group, however in the placebo group, Scr initially increased and then decreased to its preoperative value after a few days. Conclusion This study showed that intra- and early postoperative furosemide infusion has a renal protective effect in adult cardiac surgery with cardiopulmonary bypass. Although this protective effect cannot be discovered in mild renal dysfunctions, it apparently reduces the rate of the more severe renal dysfunctions. A more multidisciplinary strategy may be needed in reducing the milder renal damage. PMID:28176949

  4. The Impact of Delirium after Cardiac Surgery on Postoperative Resource Utilization

    PubMed Central

    Brown, Charles H.; Laflam, Andrew; Max, Laura; Lymar, Daria; Neufeld, Karin J.; Tian, Jing; Shah, Ashish S.; Whitman, Glenn J.; Hogue, Charles W.

    2016-01-01

    Background Delirium is a common complication after cardiac surgery and is associated with increased morbidity and mortality. However, whether rigorously-assessed postoperative delirium is associated with increased length of stay in the intensive care unit (LOS-ICU), length of stay (LOS), and hospital charges is not clear. Methods Patients (n=66) undergoing coronary artery bypass and/or valve surgery were enrolled in a nested cohort study. Rigorous delirium assessments were conducted using the Confusion Assessment Method. LOS-ICU and LOS were obtained from the medical record and hospital charges from administrative data reported to the state. Because of the skewed distribution of outcome variables, outcomes were compared using rank-sum tests, as well as median regression incorporating propensity scores. Results Patients who developed delirium (56%) vs. no delirium (43%) had increased median LOS-ICU (75.6 hours [IQR 43.6–136.8] vs. 29.7 hours [IQR 21.7–46.0]; p=0.002), increased median LOS (9 days [IQR 6–16] vs. 7 days [IQR 5–8]; p=0.006), and increased median hospital charges ($51,805 [IQR $44,041-$80,238] vs. $41,576 [IQR $35,748-$43,660]; P=0.002). In propensity score models adjusted for patient and surgical characteristics and complications, the results for LOS-ICU and cost remained highly significant, although the results for LOS were attenuated based on the specific statistical model. Increased severity of delirium was associated with both increased LOS-ICU and charges in a dose-response manner. Conclusions Delirium after cardiac surgery is independently associated with both increased length of stay-ICU and higher hospital charges. Since delirium is potentially preventable, targeted delirium-prevention protocols for high-risk patients may represent an important strategy for quality improvement. PMID:27041454

  5. Early pulmonary compliance increase during cardiac surgery predicted post-operative lung dysfunction.

    PubMed

    Sacuto, Yann; Sacuto, Thierry

    2017-06-01

    Lung dysfunction following cardiac surgery is currently viewed as the consequence of atelectasis and lung injury. While the mechanism of atelectasis has been largely detailed, the pathogenesis of lung injury after cardiopulmonary bypass is still unclear. Based upon clinical and experimental studies, we hypothesized that lungs could be injured through a mechanical phenomenon. We recorded pulmonary compliance at six key moments of a heart operation in 62 adult patients undergoing elective cardiac surgery. We focused on the period lasting from anesthetic induction to aorta unclamping. We calculated the variation of static and dynamic pulmonary compliance caused by thorax opening; ΔCstat1 and ΔCdyn1 and that caused by cardiopulmonary bypass, ΔCstat2 and ΔCdyn2. Blood gases were performed under standardized ventilation after anesthetic induction and after surgical closure. The PaO2/FiO2 ratio was calculated. ∆PaO2/FiO2 was the criterion for lung dysfunction. We compared ΔCstat1 and ΔCdyn1 with both ∆PaO2/FiO2 and, respectively, ΔCstat2 and ΔCdyn2. Static and dynamic compliance increased with the opening of the thorax and decreased with the start of cardiopulmonary bypass. The PaO2/FiO2 ratio diminished after surgery. ΔCstat1 and ΔCdyn1 were negatively correlated with both ∆PaO2/FiO2 (r=-0.42; p<0.001 and r=-0.44; p<0.001) and, respectively, with ΔCstat2 and ΔCdyn2 (r=-0.59; p<0.001 and r=-0.53; p<0.001). Increased pulmonary compliance induced by the opening of the thorax is correlated with worsened intrapulmonary shunt after cardiopulmonary bypass. A mechanical phenomenon could be partly responsible for post-operative hypoxemia.

  6. Soluble Isoform of the Receptor for Advanced Glycation End Products as a Biomarker for Postoperative Respiratory Failure after Cardiac Surgery

    PubMed Central

    Uchida, Tokujiro; Ohno, Nagara; Asahara, Miho; Yamada, Yoshitsugu; Yamaguchi, Osamu; Tomita, Makoto; Makita, Koshi

    2013-01-01

    Purpose Postoperative respiratory failure is a major problem which can prolong the stay in the intensive care unit in patients undergoing cardiac surgery. We measured the serum levels of the soluble isoform of the receptor for advanced glycation end products (sRAGE), and we studied its association with postoperative respiratory failure. Methods Eighty-seven patients undergoing elective cardiac surgery were enrolled in this multicenter observational study in three university hospitals. Serum biomarker levels were measured perioperatively, and clinical data were collected for 7 days postoperatively. The duration of mechanical ventilation was studied for 28 days. Results Serum levels of sRAGE elevated immediately after surgery (median, 1751 pg/mL; interquartile range (IQR) 1080–3034 pg/mL) compared with the level after anesthetic induction (median, 884 pg/mL; IQR, 568–1462 pg/mL). Postoperative sRAGE levels in patients undergoing off-pump coronary artery bypass grafting (median, 1193 pg/mL; IQR 737–1869 pg/mL) were significantly lower than in patients undergoing aortic surgery (median, 1883 pg/mL; IQR, 1406–4456 pg/mL; p = 0.0024) and valve surgery (median, 2302 pg/mL; IQR, 1447–3585 pg/mL; p = 0.0005), and postoperative sRAGE correlated moderately with duration of cardiopulmonary bypass (rs = 0.44, p<0.0001). Receiver operating characteristic curve analysis demonstrated that postoperative sRAGE had a predictive performance with area under the curve of 0.81 (95% confidence interval 0.71–0.88) for postoperative respiratory failure, defined as prolonged mechanical ventilation >3 days. The optimum cutoff value for prediction of respiratory failure was 3656 pg/mL, with sensitivity and specificity of 62% and 91%, respectively. Conclusions Serum sRAGE levels elevated immediately after cardiac surgery, and the range of elevation was associated with the morbidity of postoperative respiratory failure. Early postoperative sRAGE levels appear to be linked

  7. Soluble isoform of the receptor for advanced glycation end products as a biomarker for postoperative respiratory failure after cardiac surgery.

    PubMed

    Uchida, Tokujiro; Ohno, Nagara; Asahara, Miho; Yamada, Yoshitsugu; Yamaguchi, Osamu; Tomita, Makoto; Makita, Koshi

    2013-01-01

    Postoperative respiratory failure is a major problem which can prolong the stay in the intensive care unit in patients undergoing cardiac surgery. We measured the serum levels of the soluble isoform of the receptor for advanced glycation end products (sRAGE), and we studied its association with postoperative respiratory failure. Eighty-seven patients undergoing elective cardiac surgery were enrolled in this multicenter observational study in three university hospitals. Serum biomarker levels were measured perioperatively, and clinical data were collected for 7 days postoperatively. The duration of mechanical ventilation was studied for 28 days. Serum levels of sRAGE elevated immediately after surgery (median, 1751 pg/mL; interquartile range (IQR) 1080-3034 pg/mL) compared with the level after anesthetic induction (median, 884 pg/mL; IQR, 568-1462 pg/mL). Postoperative sRAGE levels in patients undergoing off-pump coronary artery bypass grafting (median, 1193 pg/mL; IQR 737-1869 pg/mL) were significantly lower than in patients undergoing aortic surgery (median, 1883 pg/mL; IQR, 1406-4456 pg/mL; p=0.0024) and valve surgery (median, 2302 pg/mL; IQR, 1447-3585 pg/mL; p=0.0005), and postoperative sRAGE correlated moderately with duration of cardiopulmonary bypass (rs  =0.44, p<0.0001). Receiver operating characteristic curve analysis demonstrated that postoperative sRAGE had a predictive performance with area under the curve of 0.81 (95% confidence interval 0.71-0.88) for postoperative respiratory failure, defined as prolonged mechanical ventilation >3 days. The optimum cutoff value for prediction of respiratory failure was 3656 pg/mL, with sensitivity and specificity of 62% and 91%, respectively. Serum sRAGE levels elevated immediately after cardiac surgery, and the range of elevation was associated with the morbidity of postoperative respiratory failure. Early postoperative sRAGE levels appear to be linked to cardiopulmonary bypass, and may have predictive

  8. Post-operative pediatric cerebellar mutism syndrome and its association with hypertrophic olivary degeneration

    PubMed Central

    Spiteri, Michaela; Kumar, Ram; Lewis, Emma; Harave, Srikrishna; Windridge, David; Ong, Chan; Pizer, Barry

    2016-01-01

    Background The dentato-thalamo-cortical (DTC) pathway is recognized as the anatomical substrate for postoperative pediatric cerebellar mutism (POPCMS), a well-recognized complication affecting up to 31% of children undergoing posterior fossa brain tumour resection. The proximal structures of the DTC pathway also form a segment of the Guillain and Mollaret triangle, a neural network which when disrupted causes hypertrophic olivary degeneration (HOD) of the inferior olivary nucleus (ION). We hypothesize that there is an association between the occurrence of POPCMS and HOD and aim to evaluate this on MR imaging using qualitative and quantitative analysis of the ION in children with and without POPCMS. Methods In this retrospective study we qualitatively analysed the follow up MR imaging in 48 children who underwent posterior fossa tumour resection for presence of HOD. Quantitative analysis of the ION was possible in 28 children and was performed using semi-automated segmentation followed by feature extraction and feature selection techniques and relevance of the features to POPCMS were evaluated. The diagnosis of POPCMS was made independently based on clinical and nursing assessment notes. Results There was significant association between POPCMS and bilateral HOD (P=0.002) but not unilateral HOD. Quantitative analysis showed that hyperintensity in the left ION was the most relevant feature in children with POPCMS. Conclusions Bilateral HOD can serve as a reliable radiological indicator in establishing the diagnosis of POPCMS particularly in equivocal cases. The strong association of signal change due to HOD in the left ION suggests that injury to the right proximal efferent cerebellar pathway plays an important role in the causation of POPCMS. PMID:27942473

  9. Postoperative myocardial infarction and cardiac death. Predictive value of dipyridamole-thallium imaging and five clinical scoring systems based on multifactorial analysis

    SciTech Connect

    Lette, J.; Waters, D.; Lassonde, J.; Dube, S.; Heyen, F.; Picard, M.; Morin, M. )

    1990-01-01

    Sixty-six patients unable to complete a standard preoperative exercise test because of physical limitations were studied to determine the predictive value of individual clinical parameters, of clinical scoring systems based on multifactorial analysis, and of dipyridamole-thallium imaging before major general and vascular surgery. Study endpoints were limited to postoperative myocardial infarction or cardiac death before hospital discharge. There were nine postoperative cardiac events (seven deaths and two nonfatal infarctions). There was no statistical correlation between cardiac events and preoperative clinical descriptors, including individual clinical parameters, the Dripps-American Surgical Association score, the Goldman Cardiac Risk Index score, the Detsky Modified Cardiac Risk Index score, Eagle's clinical markers of low surgical risk, and the probability of postoperative events as determined by Cooperman's equation. There were no cardiac events in 30 patients with normal dipyridamole-thallium scans or in nine patients with fixed myocardial perfusion defects. Of 21 patients with reversible perfusion defects who underwent surgery, nine had a postoperative cardiac event (sensitivity, 100%; specificity, 43%). In the six other patients with reversible defects, preoperative angiography showed severe coronary disease or cardiomyopathy. Thus in patients unable to complete a standard exercise stress test, postoperative outcome cannot be predicted clinically before major general and vascular surgery, whereas dipyridamole-thallium imaging successfully identified all patients who sustained a postoperative cardiac event.

  10. Utility of Postoperative Radiographs for Pediatric Scoliosis: Association Between History and Physical Examination Findings and Radiographic Findings.

    PubMed

    Shau, David N; Bible, Jesse E; Gadomski, Stephen P; Samade, Richard; Armaghani, Sheyan; Mencio, Gregory A; Devin, Clinton J

    2014-07-02

    Postoperative radiographs are routinely obtained following surgery for the correction of scoliosis in pediatric patients. The purpose of this study was to comprehensively evaluate the utility of obtaining routine postoperative radiographs in the management of these patients. A total of 1969 clinic notes and corresponding radiographs regarding 451 consecutive patients with scoliosis (age range, ten to eighteen years) who had surgical correction over a ten-year period at a single institution were retrospectively reviewed. Curve etiology, preoperative curve characteristics, and surgical procedures performed were recorded. All postoperative clinic notes and radiographs were reviewed for abnormalities and changes in treatment course. It was then determined whether clinical signs and symptoms and/or abnormal radiographic findings led to a change in treatment course, which was defined as a therapeutic intervention or further diagnostic testing. Of the 451 patients in this study (average age [and standard deviation], 14.7 ± 2.4 years), 72.5% had adolescent idiopathic scoliosis, 23.3% had neuromuscular scoliosis, and 4.2% had other underlying causes of scoliosis. A change in treatment course occurred in the cases of forty-two patients, all of whom had symptomatic findings on postoperative history and physical examination and only fifteen of whom had supportive abnormal findings on postoperative radiographs. Curve etiology and surgical procedures performed had no impact on radiographic utility. A significant increase in utility was seen for radiographs obtained at visits one year or more following surgery compared with those obtained at visits less than one year following surgery (1.7% compared with 0.3%, p = 0.001). The overall sensitivity, specificity, positive predictive value, and negative predictive value of routine postoperative radiographs in guiding treatment course were 35.7%, 98.1%, 28.8%, and 98.6%, respectively. Routine radiographs provide low utility in guiding

  11. Improved pain management in pediatric postoperative liver transplant patients using parental education and non-pharmacologic interventions.

    PubMed

    Sharek, Paul J; Wayman, Karen; Lin, Eugenia; Strichartz, Debra; Sentivany-Collins, Sandy; Good, Julie; Esquivel, Carlos; Brown, Michelle; Cox, Kenneth

    2006-03-01

    A pain management intervention, consisting of pretransplant parental education and support, pre- and postoperative behavioral pediatrics consultation, postoperative physical and occupational therapy consultation, and implementation of non-pharmacologic pain management strategies, was introduced to all pediatrics patients receiving liver transplants at Lucile Packard Children's Hospital beginning August 2001. Children receiving transplants pre-intervention (May, 2000 to February, 2001) and post-intervention (August, 2001 to March, 2002) were compared using pain scores, parent perception of pain ratings, length of stay, ventilator days, total cost, and opioid use. A total of 27 children were evaluated (13 historical control, 14 intervention). The two populations did not differ on age at transplant (mean age 53.8 vs. 63.6 months), sex (46.1% vs. 50% male), ethnicity (53.8% vs. 57.1% white, non-Hispanic) weight at transplant (17.5 vs. 24.7 kg), percent with biliary atresia as the primary reason for transplant (42.9% vs. 69.2%), percent with status 1 transplant listing score (38.5% vs. 50.0%), or public insurance status (30.8 vs. 57.2% with Medicaid). No differences were found in mean pediatric intensive care unit (PICU) postoperative length of stay (6.7 vs. 5.3 days), total postoperative length of stay (17.5 vs. 17.5 days), total inpatient length of stay (27.0 vs. 24.4 days), time to extubation (30 vs. 24.3 h), total cost (dollar 147,983 vs. dollar 157,882) or opioid use through postoperative day (POD) 6 (0.24 vs. 0.25 mg/kg/day morphine equivalent). A decrease in mean pain score between POD 0 and 6 (2.82 vs. 2.12; p = 0.047), a decrease in mean parental pain perception score (3.1 vs. 2.1; p = 0.001), and an increase in number of pain assessments per 12 h shift (3.43 vs. 6.79; p < 0.005) were seen. A comprehensive non-pharmacologic postoperative pain management program in children receiving a liver transplant was associated with decreased pain scores, improved parent

  12. Sternal wound infections in pediatric congenital cardiac surgery: a survey of incidence and preventative practice.

    PubMed

    Woodward, Cathy S; Son, Minnette; Calhoon, John; Michalek, Joel; Husain, S Adil

    2011-03-01

    Guidelines exist for prevention of sternal wound infections (SWI) in adults. There are no guidelines for pediatric patients and limited reports on SWI incidence. The purpose of this study was to determine the incidence of, and preventative practice regarding pediatric SWIs with a long-term aim to develop best practice guidelines. Eighty-nine congenital heart programs were sent a 31 question on-line survey regarding pediatric SWI. Thirty eight (43%) of the 89 programs responded. They reported 8,774 pediatric congenital procedures with a mean SWI rate of 1.53% (range, 0 to 9.09). Mean yearly volume was 237 operations (range, 50 to 720). Neither program size nor delayed sternal closure was associated with increased incidence of SWI. Variations in preoperative measures, antibiotic regimens, and wound care did not statistically impact incidence of SWI. Programs with protocols to monitor and control blood glucose levels postoperatively had statistically lower infection rates (1.04 vs 2.35, p = 0.03), and those that sent mediastinal cultures at time of delayed sternal closure reported lower infection rates (1.34 vs 1.74, p = 0.051). This report provides a multiinstitutional SWI incidence from pediatric programs of 1.53%. Despite variations in clinical practice between programs, this survey revealed two strategies resulting in reduced SWIs; protocol-based management of glucose levels and mediastinal wound cultures sent at time of closure. Pediatric programs do not consistently follow adult preventative guidelines. Multicenter randomized research is needed to formulate preventative guidelines to reduce the incidence of pediatric SWI. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  13. Public access defibrillation and outcomes after pediatric out-of-hospital cardiac arrest.

    PubMed

    Fukuda, Tatsuma; Ohashi-Fukuda, Naoko; Kobayashi, Hiroaki; Gunshin, Masataka; Sera, Toshiki; Kondo, Yutaka; Yahagi, Naoki

    2017-02-01

    Use of automated external defibrillators (AEDs) has been recommended for pediatric out-of-hospital cardiac arrest (OHCA). However, there are no conclusive studies that elucidated the effectiveness of public-access defibrillation (PAD) in children. This was a nationwide, population-based, propensity score-matched study of pediatric OHCA in Japan from 2011 to 2012, based on data from the All-Japan Utstein Registry. We included pediatric OHCA patients (aged 1-17 years) who received bystander cardiopulmonary resuscitation. The primary outcome was a favorable neurological state 1 month after OHCA (defined as a CPC score of 1-2). A total of 1193 patients were included in the final cohort; 57 received PAD and 1136 did not. Among 1193 patients, 188 (15.8%) survived with a favorable neurological status 1 month after OHCA. The odds of neurologically favorable survival were significantly higher for patients receiving PAD after adjusting for potential confounders: propensity score matching, OR 3.17 (95% CI 1.40-7.17), and multivariable logistic regression modeling, ORadjusted 5.10 (95% CI 2.01-13.70). Similar findings were observed for the secondary outcomes (i.e., neurologically favorable survival with a CPC score of 1, one-month survival, and prehospital return of spontaneous circulation). In subgroup analyses, there were no significant differences in neurologically favorable survival between the PAD group and non-PAD group in the unwitnessed cohort (ORadjusted 7.76 [0.75-81.90]) or the non-cardiac etiology cohort (ORadjusted 6.65 [0.64-66.24]). PAD was associated with an increased chance of neurologically favorable survival in pediatric OHCA (aged 1-17 years) who received bystander CPR, except for in cases of unwitnessed or non-cardiac etiology. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  14. Pediatric cardiac-gated CT angiography: assessment of radiation dose.

    PubMed

    Hollingsworth, Caroline L; Yoshizumi, Terry T; Frush, Donald P; Chan, Frandics P; Toncheva, Greta; Nguyen, Giao; Lowry, Carolyn R; Hurwitz, Lynne M

    2007-07-01

    The purpose of our study was to determine a dose range for cardiac-gated CT angiography (CTA) in children. ECG-gated cardiac CTA simulating scanning of the heart was performed on an anthropomorphic phantom of a 5-year-old child on a 16-MDCT scanner using variable parameters (small field of view; 16 x 0.625 mm configuration; 0.5-second gantry cycle time; 0.275 pitch; 120 kVp at 110, 220, and 330 mA; and 80 kVp at 385 mA). Metal oxide semiconductor field effect transistor (MOSFET) technology measured 20 organ doses. Effective dose calculated using the dose-length product (DLP) was compared with effective dose determined from measured absorbed organ doses. Highest organ doses included breast (3.5-12.6 cGy), lung (3.3-12.1 cGy), and bone marrow (1.7-7.6 cGy). The 80 kVp/385 mA examination produced lower radiation doses to all organs than the 120 kVp/220 mA examination. MOSFET effective doses (+/- SD) were as follows: 110 mA: 7.4 mSv (+/- 0.6 mSv), 220 mA: 17.2 mSv (+/- 0.3 mSv), 330 mA: 25.7 mSv (+/- 0.3 mSv), 80 kVp/385 mA: 10.6 mSv (+/- 0.2 mSv). DLP effective doses for diagnostic runs were as follows: 110 mA: 8.7 mSv, 220 mA: 19 mSv, 330 mA: 28 mSv, 80 kVp/385 mA: 12 mSv. DLP effective doses exceeded MOSFET effective doses by 9.7-17.2%. Radiation doses for a 5-year-old during cardiac-gated CTA vary greatly depending on parameters. Organ doses can be high; the effective dose may reach 28.4 mSv. Further work, including determination of size-appropriate mA and image quality, is important before routine use of this technique in children.

  15. Elevated postoperative serum procalcitonin is not indicative of bacterial infection in cardiac surgical patients.

    PubMed

    Chakravarthy, Murali; Kavaraganahalli, Deepak; Pargaonkar, Sumant; Hosur, Rajathadri; Harivelam, Chidananda; Bharadwaj, Ashwin; Raghunathan, Aditi

    2015-01-01

    Identifying infections early, commencing appropriate empiric antibiotic not only helps gain control early, but also reduces mortality and morbidity. Conventional cultures take about 5 days to identify infections. To identify the infections early biomarker like serum procalcitonin (SPC). We studied the correlation of an elevated level of SPC and positive culture in elective adult patients undergoing cardiac surgery. This prospective study was conducted from January to December 2013. SPC was checked in patients showing evidence of sepsis. Simultaneously, relevant culture was also undertaken. Correlation, specificity, and sensitivity of elevated SPC were checked. A total of 819 adult patients were included in the study. 43 of them had signs of infection and SPC levels were checked. Based on the level of SPC criteria, 10 patients were diagnosed as "nil", out of them, 4 had culture-positive infections, 17 were suggested to have "mild infection," 3 out those had culture positivity. None among the eleven patients suggested to have "moderate infection," had a positive culture, and one among the five suggested to have a severe infection had a positive culture. The sensitivity was 50% and the specificity 17%. The positive predictive value was 12% and the negative predictive value 60%. We failed to elicit positive correlation between elevated SPC levels and postoperative infection in cardio surgical patients.

  16. A pilot study of cerebrovascular reactivity autoregulation after pediatric cardiac arrest

    PubMed Central

    Lee, Jennifer K.; Brady, Ken M.; Chung, Shang-En; Jennings, Jacky M.; Whitaker, Emmett E.; Aganga, Devon; Easley, Ronald B.; Heitmiller, Kerry; Jamrogowicz, Jessica L.; Larson, Abby C.; Lee, Jeong-Hoo; Jordan, Lori C.; Hogue, Charles W.; Lehmann, Christoph U.; Bembea, Mela M.; Hunt, Elizabeth A.; Koehler, Raymond C.; Shaffner, Donald H.

    2014-01-01

    Aim Improved survival after cardiac arrest has placed greater emphasis on neurologic resuscitation. The purpose of this pilot study was to evaluate the relationship between cerebrovascular autoregulation and neurologic outcomes after pediatric cardiac arrest. Methods Children resuscitated from cardiac arrest had autoregulation monitoring during the first 72 hours after return of circulation with an index derived from near-infrared spectroscopy in a pilot study. The range of mean arterial blood pressure (MAP) with optimal vasoreactivity (MAPOPT) was identified. The area under the curve (AUC) of the time spent with MAP below MAPOPT and MAP deviation below MAPOPT was calculated. Neurologic outcome measures included placement of a new tracheostomy or gastrostomy, death from a primary neurologic etiology (brain death or withdrawal of support for neurologic futility), and change in the Pediatric Cerebral Performance Category score (ΔPCPC). Results Thirty-six children were monitored. Among children who did not require extracorporeal membrane oxygenation (ECMO), children who received a tracheostomy/gastrostomy had greater AUC during the second 24 hours after resuscitation than those who did not (P=0.04; n=19). Children without ECMO who died from a neurologic etiology had greater AUC during the first 48 hours than did those who lived or died from cardiovascular failure (P=0.04; n=19). AUC below MAPOPT was not associated with ΔPCPC when children with or without ECMO were analyzed separately. Conclusions Deviation from the blood pressure with optimal autoregulatory vasoreactivity may predict poor neurologic outcomes after pediatric cardiac arrest. This experimental autoregulation monitoring technique may help individualize blood pressure management goals after resuscitation. PMID:25046743

  17. Diagnosis of cardiac disease in pediatric end-stage renal disease

    PubMed Central

    Chavers, Blanche M.; Solid, Craig A.; Sinaiko, Alan; Daniels, Frank X.; Chen, Shu-Cheng; Collins, Allan J.; Frankenfield, Diane L.; Herzog, Charles A.

    2011-01-01

    Background. Cardiac disease is a significant cause of morbidity and mortality in children with end-stage renal disease (ESRD). This study aimed to report the frequency of cardiac disease diagnostic methods used in US pediatric maintenance hemodialysis patients. Methods. A cross-sectional analysis of all US pediatric (ages 0.7–18 years, n = 656) maintenance hemodialysis patients was performed using data from the Centers for Medicare and Medicaid Services ESRD Clinical Performance Measures Project. Clinical and laboratory information was collected in 2001. Results were analysed by age, sex, race, Hispanic ethnicity, dialysis duration, body mass index (BMI), primary ESRD cause and laboratory data. Results. Ninety-two percent of the patients had a cardiovascular risk factor (63% hypertension, 38% anemia, 11% BMI > 94th percentile, 63% serum phosphorus > 5.5 mg/dL and 55% calcium–phosphorus product ≥ 55 mg2/dL2). A diagnosis of cardiac disease was reported in 24% (n = 155) of all patients: left ventricular hypertrophy/enlargement 17%, congestive heart failure/pulmonary edema 8%, cardiomyopathy 2% and decreased left ventricular function 2%. Thirty-one percent of patients were not tested. Of those tested, the diagnostic methods used were chest X-rays in 60%, echocardiograms in 35% and electrocardiograms in 33%; left ventricular hypertrophy/enlargement was diagnosed using echocardiogram (72%), chest X-ray (20%) and electrocardiogram (15%). Conclusions. Although 92% of patients had cardiovascular risk factors, an echocardiography was performed in only one-third of the patients. Our study raises the question of why echocardiography, considered the gold standard for cardiac disease diagnosis, has been infrequently used in pediatric maintenance dialysis patients, a high-risk patient population. PMID:20861193

  18. Cardiac dysfunction and ferritin as early markers of severity in pediatric sepsis.

    PubMed

    Tonial, Cristian T; Garcia, Pedro Celiny R; Schweitzer, Louise Cardoso; Costa, Caroline A D; Bruno, Francisco; Fiori, Humberto H; Einloft, Paulo R; Garcia, Ricardo Branco; Piva, Jefferson Pedro

    The aim of this study was to verify the association of echocardiogram, ferritin, C-reactive protein, and leukocyte count with unfavorable outcomes in pediatric sepsis. A prospective cohort study was carried out from March to December 2014, with pediatric critical care patients aged between 28 days and 18 years. Inclusion criteria were diagnosis of sepsis, need for mechanical ventilation for more than 48h, and vasoactive drugs. Serum levels of C-reactive protein, ferritin, and leukocyte count were collected on the first day (D0), 24h (D1), and 72h (D3) after recruitment. Patients underwent transthoracic echocardiography to determine the ejection fraction of the left ventricle on D1 and D3. The outcomes measured were length of hospital stay and in the pediatric intensive care unit, mechanical ventilation duration, free hours of VM, duration of use of inotropic agents, maximum inotropic score, and mortality. Twenty patients completed the study. Patients with elevated ferritin levels on D0 had also fewer ventilator-free hours (p=0.046) and higher maximum inotropic score (p=0.009). Patients with cardiac dysfunction by echocardiogram on D1 had longer hospital stay (p=0.047), pediatric intensive care unit stay (p=0.020), duration of mechanical ventilation (p=0.011), maximum inotropic score (p=0.001), and fewer ventilator-free hours (p=0.020). Cardiac dysfunction by echocardiography and serum ferritin value was significantly associated with unfavorable outcomes in pediatric patients with sepsis. Copyright © 2017 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.

  19. The impact of intra-operative sufentanil dosing on post-operative pain, hyperalgesia and morphine consumption after cardiac surgery.

    PubMed

    Fechner, J; Ihmsen, H; Schüttler, J; Jeleazcov, C

    2013-04-01

    There is an ongoing debate whether opioids when used for intra-operative analgesia may enhance post-operative pain. We studied the effect of two different intra-operative dosings of sufentanil on post-operative morphine consumption, pain and hyperalgesia after cardiac anaesthesia. Forty-two male patients (age: 48-74 years) undergoing first-time coronary artery bypass graft surgery were randomized to one of two groups receiving total intravenous anaesthesia with propofol and a target controlled infusion of sufentanil with a target of 0.4 ng/mL (group SL, n = 20) or 0.8 ng/mL (group SH, n = 22) plasma concentration. Post-operative morphine requirement in the first 48 h was assessed using patient-controlled analgesia (PCA). Pain rating during deep inspiration, and the extent of primary and secondary hyperalgesia near the sternotomy wound were assessed. The post-operative morphine requirements in the first 48 h were 0.68 ± 0.21 mg/kg in group SL and 0.96 ± 0.44 mg/kg in group SH (p < 0.05). In group SL, pain during deep inspiration was significantly lower on the first post-operative day (p < 0.05). Primary hyperalgesia had its maximum on the second and third post-operative day, without a difference between the two groups. The extent of secondary mechanical pinprick hyperalgesia was not different between the groups. Intra-operative dosing of sufentanil significantly influenced post-operative morphine consumption, pain and hyperalgesia. For cardiac anaesthesia in combination with propofol, a sufentanil target concentration of 0.4 ng/mL may be preferable. © 2012 European Federation of International Association for the Study of Pain Chapters.

  20. Intraoperative usefulness and postoperative results of the endoilluminator for performing primary posterior capsulectomy and anterior vitrectomy during pediatric cataract surgery

    PubMed Central

    Matalia, J; Anaspure, H; Shetty, B K; Matalia, H

    2014-01-01

    Purpose To analyze the intraoperative usefulness and postoperative results of endoilluminator use during pediatric cataract surgery. Methods Medical records of children <8 years of age who underwent lens aspiration with primary posterior capsulectomy (PPC) and anterior vitrectomy (AV) with or without intraocular lens implantation (IOL) were studied. An endoilluminator was used intraoperatively as an external light source in all cases to ensure the completeness of PPC and adequacy of AV. All children were divided into three groups depending upon the age at surgery and presence of IOL. We included only the first operated eye in bilateral cases. We studied the intraoperative performance for all and postoperative complications for those with >6 months follow-up. Results The charts of 79 eyes of 46 children (26 boys, 20 girls: 33 bilateral, 13 unilateral) were reviewed, of which we analyzed 46 eyes of 46 children for intraoperative performance and 42 eyes of 42 children for postoperative complications. The intraoperatively adequate size of PPC was obtained in all cases with no vitreous in the anterior chamber. Two cases in the first group developed peaking of the pupil, and one case developed visual axis contraction requiring membranectomy. None of the cases in the other groups developed any complication. Conclusion An endoilluminator is a simple, safe, and powerful tool for better visualization of the posterior capsule and anterior vitreous during pediatric cataract surgery. It helps in confirming a good vitrectomy, ensuring its completeness and thereby reducing the chances of any complication due to inadequate AV. PMID:24946844

  1. Epidemiology and outcome of major postoperative infections following cardiac surgery: Risk factors and impact of pathogen type

    PubMed Central

    Chen, Luke F.; Arduino, Jean Marie; Sheng, Shubin; Muhlbaier, Lawrence H.; Kanafani, Zeina A.; Harris, Anthony D.; Fraser, Thomas G.; Allen, Keith; Corey, G. Ralph; Fowler, Vance G.

    2012-01-01

    Background Major postoperative infections (MPIs) are poorly understood complications of cardiac surgery. We examined the epidemiology, microbiology, and outcome of MPIs occurring after cardiac surgery. Methods The study cohort was drawn from the Society of Thoracic Surgeon National Cardiac Database and comprised adults who underwent cardiac surgery at 5 tertiary hospitals between 2000 and 2004. We studied the incidence, microbiology, and risk factors of MPI (bloodstream or chest wound infections within 30 days after surgery), as well as 30-day mortality. We used multivariate regression analyses to evaluate the risk of MPI and mortality. Results MPI was identified in 341 of 10,522 patients (3.2%). Staphylococci were found in 52.5% of these patients, gram-negative bacilli (GNB) in 24.3%, and other pathogens in 23.2%. High body mass index, previous coronary bypass surgery, emergency surgery, renal impairment, immunosuppression, cardiac failure, and peripheral/cerebrovascular disease were associated with the development of MPI. Median postoperative duration of hospitalization (15 days vs 6 days) and mortality (8.5% vs 2.2%) were higher in patients with MPIs. Compared with uninfected individuals, odds of mortality were higher in patients with S aureus MPIs (adjusted odds ratio, 3.7) and GNB MPIs (adjusted odds ratio, 3.0). Conclusions Staphylococci accounted for the majority of MPIs after cardiac surgery. Mortality was higher in patients with Staphylococcus aureus- and GNB-related MPIs than in patients with MPIs caused by other pathogens and uninfected patients. Preventive strategies should target likely pathogens and high-risk patients undergoing cardiac surgery. PMID:22609237

  2. Incidence of Postoperative Deep Venous Thrombosis Is Higher among Cardiac and Vascular Surgery Patients as Compared with General Surgery Patients.

    PubMed

    Aziz, Faisal; Patel, Mayank; Ortenzi, Gail; Reed, Amy B

    2015-01-01

    Unlike general surgery patients, most of vascular and cardiac surgery patients receive therapeutic anticoagulation during operations. The purpose of this study was to report the incidence of deep venous thrombosis (DVT) among cardiac and vascular surgery patients, compared with general surgery. The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent surgical procedures from 2005 to 2010. Patients who developed DVT within 30 days of an operation were identified. The incidence of DVT was compared among vascular, general, and cardiac surgery patients. Risk factors for developing postoperative DVT were identified and compared among these patients. Of total 2,669,772 patients underwent surgical operations in the period between 2005 and 2010. Of all the patients, 18,670 patients (0.69%) developed DVT. The incidence of DVT among different surgical specialties was cardiac surgery (2%), vascular surgery (0.99%), and general surgery (0.66%). The odds ratio for developing DVT was 1.5 for vascular surgery patients and 3 for cardiac surgery patients, when compared with general surgery patients (P < 0.001). The odds ratio for developing DVT after cardiac surgery was 2, when compared with vascular surgery (P < 0.001). The incidence of DVT is higher among vascular and cardiac surgery patients as compared with that of general surgery patients. Intraoperative anticoagulation does not prevent the occurrence of DVT in the postoperative period. These patients should receive DVT prophylaxis in the perioperative period, similar to other surgical patients according to evidence-based guidelines. Copyright © 2015 Elsevier Inc. All rights reserved.

  3. Analysis of clinical parameters and cardiac magnetic resonance imaging as predictors of outcome in pediatric myocarditis.

    PubMed

    Sachdeva, Shagun; Song, Xiaoyan; Dham, Niti; Heath, Deneen M; DeBiasi, Roberta L

    2015-02-15

    Myocarditis causes significant morbidity and mortality in pediatric patients, with potential adverse outcomes including heart failure, transplantation requirement, and/or death. The objective of this study was to determine predictors of early and late poor outcomes, defined as requirement for extracorporeal membrane oxygenation, ventricular assist device, transplantation, or death in pediatric myocarditis patients. A retrospective cohort study was conducted to evaluate pediatric myocarditis presenting over a 5-year period at a pediatric institution. Patients were identified using an institutional heart failure database and International Classification of Diseases, Ninth Revision, discharge diagnosis codes for myocarditis and confirmed by review of medical records. Data extraction included epidemiologic factors, the presenting ejection fraction (EF), initial and peak troponin levels, brain natriuretic peptide (BNP) level, pathogen identification, cardiac magnetic resonance imaging (MRI), and outcomes. Univariate and multivariate regression was performed to identify variables predictive of outcomes. Because published pediatric cardiac MRI data are sparse, whether late enhancement was associated with specific clinical variables or predictive of outcomes was also evaluated. Fifty-eight patients were identified. The mean age was 10.5 years, 64% were male, 62% were Caucasian, 15% were African-American, and 23% were Hispanic or Asian. Eighty-one percent presented at the institution <1 week after symptom onset. Presenting EFs were normal (>50%) or mildly decreased (40% to 50%) in 48%, moderately decreased (30% to 40%) in 9%, and severely decreased (<30%) in 42%. Thirty patients (52%) underwent viral studies; 17 of these (56%) had acute viral origins of myocarditis identified, including 8 with parvovirus (2 with influenza coinfection), 7 with enterovirus, 1 with Epstein-Barr virus, and 1 with cytomegalovirus. Twenty-eight percent had poor outcomes. Univariate analysis

  4. Targeted Temperature Management After Pediatric Cardiac Arrest Due To Drowning: Outcomes and Complications.

    PubMed

    Moler, Frank W; Hutchison, Jamie S; Nadkarni, Vinay M; Silverstein, Faye S; Meert, Kathleen L; Holubkov, Richard; Page, Kent; Slomine, Beth S; Christensen, James R; Dean, J Michael

    2016-08-01

    To describe outcomes and complications in the drowning subgroup from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital trial. Exploratory post hoc cohort analysis. Twenty-four PICUs. Pediatric drowning cases. Therapeutic hypothermia versus therapeutic normothermia. An exploratory study of pediatric drowning from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital trial was conducted. Comatose patients aged more than 2 days and less than 18 years were randomized up to 6 hours following return-of-circulation to hypothermia (n = 46) or normothermia (n = 28). Outcomes assessed included 12-month survival with a Vineland Adaptive Behavior Scale score of greater than or equal to 70, 1-year survival rate, change in Vineland Adaptive Behavior Scale-II score from prearrest to 12 months, and select safety measures. Seventy-four drowning cases were randomized. In patients with prearrest Vineland Adaptive Behavior Scale-II greater than or equal to 70 (n = 65), there was no difference in 12-month survival with Vineland Adaptive Behavior Scale-II score of greater than or equal to 70 between hypothermia and normothermia groups (29% vs 17%; relative risk, 1.74; 95% CI, 0.61-4.95; p = 0.27). Among all evaluable patients (n = 68), the Vineland Adaptive Behavior Scale-II score change from baseline to 12 months did not differ (p = 0.46), and 1-year survival was similar (49% hypothermia vs 42%, normothermia; relative risk, 1.16; 95% CI, 0.68-1.99; p = 0.58). Hypothermia was associated with a higher prevalence of positive bacterial culture (any blood, urine, or respiratory sample; 67% vs 43%; p = 0.04); however, the rate per 100 days at risk did not differ (11.1 vs 8.4; p = 0.46). Cumulative incidence of blood product use, serious arrhythmias, and 28-day mortality were not different. Among patients with cardiopulmonary resuscitation durations more than 30 minutes or epinephrine doses greater than 4, none had favorable Pediatric Cerebral

  5. Assessment of Preoperative Anxiety in Cardiac Surgery Patients Lacking a History of Anxiety: Contributing Factors and Postoperative Morbidity.

    PubMed

    Hernández-Palazón, Joaquín; Fuentes-García, Diego; Falcón-Araña, Luis; Roca-Calvo, María José; Burguillos-López, Sebastián; Doménech-Asensi, Paloma; Jara-Rubio, Rubén

    2017-04-26

    The aim of this study was to measure the level of preoperative anxiety in patients scheduled for cardiac surgery, identify any influencing clinical factors, and assess the relationship between anxiety and postoperative morbidity. A prospective and consecutive study. A single university hospital. The study comprised 200 patients scheduled for cardiac surgery. Each patient was asked to grade his or her preoperative anxiety level using the Visual Analogue Scale for Anxiety, Amsterdam Preoperative Anxiety and Information Scale, and set of specific anxiety-related questions. Demographic data (age, sex, body mass index) and anesthetic and surgical data (American Society of Anesthesiologists physical status, EuroSCORE surgical risk, preoperative length of stay, and previous anesthetic experience) were registered. Also, postoperative morbidity was assessed. Twenty-eight percent of the patients developed high preoperative anxiety. The mean Amsterdam Preoperative Anxiety and Information Scale score was 11.4 ± 4.3, and the mean Visual Analogue Scale for Anxiety score was 48 ± 21. Patients scheduled for coronary artery bypass surgery, who had no previous anesthetic experience, and who were hospitalized before surgery, had higher anxiety scores. Coronary bypass surgery (odds ratio 3.026; 1.509-6.067; p = 0.002) was associated independently with preoperative high-level anxiety. Anxiety most commonly was caused by waiting for surgery, not knowing what is happening, fearing not being able to awaken from anesthesia, and being at the mercy of staff. Anxiety did not modify the postoperative course. In patients waiting to undergo cardiac surgery, both fear of the unknown and lack of information, especially related to the surgery, are crucial factors in high levels of preoperative anxiety in cardiac surgery. Coronary bypass surgery is a determining factor for preoperative anxiety. The anxiety level did not modify the postoperative course in these patients. Copyright © 2017 Elsevier

  6. Xenon for the prevention of postoperative delirium in cardiac surgery: study protocol for a randomized controlled clinical trial.

    PubMed

    Al Tmimi, Layth; Van de Velde, Marc; Herijgers, Paul; Meyns, Bart; Meyfroidt, Geert; Milisen, Koen; Fieuws, Steffen; Coburn, Mark; Poesen, Koen; Rex, Steffen

    2015-10-09

    Postoperative delirium (POD) is a manifestation of acute postoperative brain dysfunction that is frequently observed after cardiac surgery. POD is associated with short-term complications such as an increase in mortality, morbidity, costs and length of stay, but can also have long-term sequelae, including persistent cognitive deficits, loss of independence, and increased mortality for up to 2 years. The noble gas xenon has been demonstrated in various models of neuronal injury to exhibit remarkable neuroprotective properties. We therefore hypothesize that xenon anesthesia reduces the incidence of POD in elderly patients undergoing cardiac surgery with the use of cardiopulmonary bypass. One hundred and ninety patients, older than 65 years, and scheduled for elective cardiac surgery, will be enrolled in this prospective, randomized, controlled trial. Patients will be randomized to receive general anesthesia with either xenon or sevoflurane. Primary outcome parameter will be the incidence of POD in the first 5 postoperative days. The occurrence of POD will be assessed by trained research personnel, blinded to study group, with the validated 3-minute Diagnostic Confusion Assessment Method (3D-CAM) (on the intensive care unit in its version specifically adapted for the ICU), in addition to chart review and the results of delirium screening tools that will be performed by the bedside nurses). Secondary outcome parameters include duration and severity of POD, and postoperative cognitive function as assessed with the Mini-Mental State Examination. Older patients undergoing cardiac surgery are at particular risk to develop POD. Xenon provides remarkable hemodynamic stability and has been suggested in preclinical studies to exhibit neuroprotective properties. The present trial will assess whether the promising profile of xenon can be translated into a better outcome in the geriatric population. EudraCT Identifier: 2014-005370-11 (13 May 2015).

  7. Multicenter cohort study of out-of-hospital pediatric cardiac arrest.

    PubMed

    Moler, Frank W; Donaldson, Amy E; Meert, Kathleen; Brilli, Richard J; Nadkarni, Vinay; Shaffner, Donald H; Schleien, Charles L; Clark, Robert S B; Dalton, Heidi J; Statler, Kimberly; Tieves, Kelly S; Hackbarth, Richard; Pretzlaff, Robert; van der Jagt, Elise W; Pineda, Jose; Hernan, Lynn; Dean, J Michael

    2011-01-01

    To describe a large cohort of children with out-of-hospital cardiac arrest with return of circulation and to identify factors in the early postarrest period associated with survival. These objectives were for planning an interventional trial of therapeutic hypothermia after pediatric cardiac arrest. A retrospective cohort study was conducted at 15 Pediatric Emergency Care Applied Research Network clinical sites over an 18-month study period. All children from 1 day (24 hrs) to 18 yrs of age with out-of-hospital cardiac arrest and a history of at least 1 min of chest compressions with return of circulation for at least 20 mins were eligible. One hundred thirty-eight cases met study entry criteria; the overall mortality was 62% (85 of 138 cases). The event characteristics associated with increased survival were as follows: weekend arrests, cardiopulmonary resuscitation not ongoing at hospital arrival, arrest rhythm not asystole, no atropine or NaHCO3, fewer epinephrine doses, shorter duration of cardiopulmonary resuscitation, and drowning or asphyxial arrest event. For the 0- to 12-hr postarrest return-of-circulation period, absence of any vasopressor or inotropic agent (dopamine, epinephrine) use, higher lowest temperature recorded, greater lowest pH, lower lactate, lower maximum glucose, and normal pupillary responses were all associated with survival. A multivariate logistic model of variables available at the time of arrest, which controlled for gender, age, race, and asystole or ventricular fibrillation/ventricular tachycardia anytime during the arrest, found the administration of atropine and epinephrine to be associated with mortality. A second model using additional information available up to 12 hrs after return of circulation found 1) preexisting lung or airway disease; 2) an etiology of arrest drowning or asphyxia; 3) higher pH, and 4) bilateral reactive pupils to be associated with lower mortality. Receiving more than three doses of epinephrine was

  8. Are there benefits to a fresh whole blood vs. packed red blood cell cardiopulmonary bypass prime on outcomes in neonatal and pediatric cardiac surgery?

    PubMed

    Valleley, Melinda S; Buckley, Klayton W; Hayes, Kylie M; Fortuna, Randall R; Geiss, Dale M; Holt, David W

    2007-09-01

    Techniques for pediatric cardiac surgery requiring cardiopulmonary bypass (CPB) have significantly improved over the years. The use of fresh whole blood (FWB) and pre-bypass ultrafiltration (PBUF) has been suggested as means for improving perioperative and postoperative outcomes. It is the intent of this study to show that fresh whole blood along with PBUF will result in balanced CPB prime that can offer a reduction in blood product exposures and blood loss along with improving several measured postoperative outcomes. After institutional review board approval, a retrospective review was conducted on 100 patients to analyze the benefits of FWB and PBUF on outcomes in neonatal and pediatric cardiac surgery. Data analysis included preoperative and CPB data, perioperative inotrope and blood product exposure, and postoperative blood loss and blood product exposure measured for up to a 12-hour period in the intensive care unit (ICU). The three groups compared were FWB prime vs. packed red blood cell (PRBC) prime, < 5 kg FWB prime vs. < 5 kg PRBC prime, and 5+ kg FWB prime and 5+ kg PRBC prime. Cumulative blood product exposures for the FWB prime group found 62% received one blood exposure for the operative and postoperative period (p < .0001). The majority of patients who received a PRBC prime (64%) received three or more cumulative exposures (p < .0003). The < 5 kg FWB group also received significantly less cumulative blood exposure, with 64% receiving just one exposure. Comparatively, 85% of the < 5 kg PRBC patients received three or more blood product exposures perioperatively and postoperatively (p < .0001). Perioperative inotrope and postoperative blood loss did not differ among the groups. Outcomes for intraoperative death, intraoperative extubation, delayed sternal closure, and mediastinal reexploration were also not statistically different. The results of this study found that FWB leads to significantly less blood exposure, specifically in the < 5-kg population

  9. Stroke in Children With Cardiac Disease: Report From the International Pediatric Stroke Study Group Symposium

    PubMed Central

    Sinclair, Adriane J.; Fox, Christine K.; Ichord, Rebecca N.; Almond, Christopher S.; Bernard, Timothy J.; Beslow, Lauren A.; Chan, Anthony K.C.; Cheung, Michael; deVeber, Gabrielle; Dowling, Michael M.; Friedman, Neil; Giglia, Therese M.; Guilliams, Kristin P.; Humpl, Tilman; Licht, Daniel J.; Mackay, Mark T.; Jordan, Lori C.

    2016-01-01

    BACKGROUND Cardiac disease is a leading cause of stroke in children, yet limited data support the current stroke prevention and treatment recommendations. A multidisciplinary panel of clinicians was convened in February 2014 by the International Pediatric Stroke Study group to identify knowledge gaps and prioritize clinical research efforts for children with cardiac disease and stroke. RESULTS Significant knowledge gaps exist, including a lack of data on stroke incidence, predictors, primary and secondary stroke prevention, hyperacute treatment, and outcome in children with cardiac disease. Commonly used diagnostic techniques including brain computed tomography and ultrasound have low rates of stroke detection, and diagnosis is frequently delayed. The challenges of research studies in this population include epidemiologic barriers to research such as small patient numbers, heterogeneity of cardiac disease, and coexistence of multiple risk factors. Based on stroke burden and study feasibility, studies involving mechanical circulatory support, single ventricle patients, early stroke detection strategies, and understanding secondary stroke risk factors and prevention are the highest research priorities over the next 5-10 years. The development of large-scale multicenter and multispecialty collaborative research is a critical next step. The designation of centers of expertise will assist in clinical care and research. CONCLUSIONS There is an urgent need for additional research to improve the quality of evidence in guideline recommendations for cardiogenic stroke in children. Although significant barriers to clinical research exist, multicenter and multispecialty collaboration is an important step toward advancing clinical care and research for children with cardiac disease and stroke. PMID:25532775

  10. Minimally invasive transxiphoid approach for management of pediatric cardiac tamponade – one center's experience

    PubMed Central

    Haponiuk, Ireneusz; Kwasniak, Ewelina; Chojnicki, Maciej; Steffens, Mariusz; Sendrowska, Aneta; Gierat-Haponiuk, Katarzyna; Leszczyńska, Katarzyna; Paczkowski, Konrad; Zielinski, Jacek

    2015-01-01

    Introduction Cardiac tamponade is excessive collection of fluid in the pericardial sac surrounding the heart that leads to restriction of cardiac function and causes critical cardiogenic shock and rapid circulatory depression. Despite the potential variety of different etiologies in the face of a dangerous decrease of cardiac output, the emergency life-saving procedure is surgical pericardial fluid evacuation. Aim To perform a retrospective analysis of clinical data and the results of minimally invasive transxiphoid pediatric cardiac tamponade evacuation procedures performed in a cardiac surgery center. Material and methods We performed a retrospective analysis of all consecutive patients referred for treatment in our department in a period of 6 years (15 patients) who underwent emergency pericardial drainage after an echocardiographically proven diagnosis. The procedure of choice was minimally invasive transxiphoid fluid evacuation with routine pericardial drainage. Retrospective operative data analysis was performed: clinical symptoms, pre-admission and initial emergency diagnostics and interventions, the morphology and total amount of drained pericardial fluid, length of stay, final results, and overall survival rate. We introduced an original pediatric tamponade index (PTI). The PTI was analyzed according to catecholamine support before the drainage and the length of hospital stay after the procedure. Results All patients survived the procedure. No early complications of the presented minimally invasive subxiphoid approach were noted. Mean PTI in patients with intensive catecholamine support before the operation was significantly higher than in patients without it. Conclusions Minimally invasive surgical transxiphoid interventions appear to be a safe and effective method to provide life-saving support with retrieval of the fluid for further laboratory investigations. PMID:25960801

  11. Results of emergency coronary artery bypass grafting for acute myocardial infarction: importance of intraoperative and postoperative cardiac medical therapy.

    PubMed

    Sezai, Akira; Hata, Mitsumasa; Yoshitake, Isamu; Kimura, Haruka; Takahashi, Kana; Hata, Hiroaki; Shiono, Motomi

    2012-01-01

    The results of emergency coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) are less than satisfactory, and readmission for cardiac events is common. 105 patients underwent emergency CABG for AMI. We examined the long-term results of emergency CABG for AMI from the viewpoints of preoperative, intraoperative, and postoperative factors. The operative mortality rate was 11.4%. Risk factors for early death were age ≥80 years, shock, veno-arterial bypass, creatine kinase isoenzyme Mb ≥100 U/L, non-use of a left internal thoracic artery graft and an extracorporeal circulation time ≥120 min. Risk factors for late cardiac events were ejection fraction <40%, non-use of human atrial natriuretic peptide (hANP) therapy, angiotensin II receptor blockers (ARB) and aldosterone blockers, and a 3-month postoperative brain natriuretic peptide level ≥200 pg/ml. Early results of this study are similar to those seen in previous reports, whereas late phase results yield some new and interesting findings. We suggest that intraoperative hANP, and postoperative aldosterone blocker and ARB, following CABG for AMI, will, through control of the renin-angiotensin-aldsterone system, inhibit left ventricular remodelling, reduce the extent of infarction, and improve cardiac function, yielding a favourable long-term prognosis.

  12. Functional Outcome Trajectories After Out-of-Hospital Pediatric Cardiac Arrest.

    PubMed

    Silverstein, Faye S; Slomine, Beth S; Christensen, James; Holubkov, Richard; Page, Kent; Dean, J Michael; Moler, Frank W

    2016-12-01

    To analyze functional performance measures collected prospectively during the conduct of a clinical trial that enrolled children (up to age 18 yr old), resuscitated after out-of-hospital cardiac arrest, who were at high risk of poor outcomes. Children with Glasgow Motor Scale score less than 5, within 6 hours of resuscitation, were enrolled in a clinical trial that compared two targeted temperature management interventions (THAPCA-OH, NCT00878644). The primary outcome, 12-month survival with Vineland Adaptive Behavior Scale, second edition, score greater or equal to 70, did not differ between groups. Thirty-eight North American PICUs. Two hundred ninety-five children were enrolled; 270 of 295 had baseline Vineland Adaptive Behavior Scale, second edition, scores greater or equal to 70; 87 of 270 survived 1 year. Targeted temperatures were 33.0°C and 36.8°C for hypothermia and normothermia groups. Baseline measures included Vineland Adaptive Behavior Scale, second edition, Pediatric Cerebral Performance Category, and Pediatric Overall Performance Category. Pediatric Cerebral Performance Category and Pediatric Overall Performance Category were rescored at hospital discharges; all three were scored at 3 and 12 months. In survivors with baseline Vineland Adaptive Behavior Scale, second edition scores greater or equal to 70, we evaluated relationships of hospital discharge Pediatric Cerebral Performance Category with 3- and 12-month scores and between 3- and 12-month Vineland Adaptive Behavior Scale, second edition, scores. Hospital discharge Pediatric Cerebral Performance Category scores strongly predicted 3- and 12-month Pediatric Cerebral Performance Category (r = 0.82 and 0.79; p < 0.0001) and Vineland Adaptive Behavior Scale, second edition, scores (r = -0.81 and -0.77; p < 0.0001). Three-month Vineland Adaptive Behavior Scale, second edition, scores strongly predicted 12-month performance (r = 0.95; p < 0.0001). Hypothermia treatment did not alter these

  13. Sudden benzodiazepine-induced resolution of post-operative pediatric cerebellar mutism syndrome: a clinical-SPECT study.

    PubMed

    Nicita, Francesco; Paiano, Milena; Liberatore, Mauro; Spalice, Alberto; Papoff, Paola; Ullo, Mariacristina; Piccirilli, Manolo; Clerico, Anna; Schiavetti, Amalia

    2017-03-01

    Post-operative pediatric cerebellar mutism syndrome (PPCMS) is a clinical syndrome arising from cerebellar injury and characterized by absence of speech and other possible symptoms and signs. Rare reports described some benefit after administration of dopamine agonist therapy, but no treatment has proven efficacy. In this paper, we report on the dramatic, sudden resolution of PPCMS induced by midazolam administration in a boy who underwent posterior fossa surgery for choroid plexus papilloma of the fourth ventricle. In addition to clinical improvement, post-midazolam single-photon emission computed tomography also demonstrated amelioration of brain perfusion.

  14. Safety and postoperative adverse events in pediatric airway reconstruction: Analysis of ACS-NSQIP-P 30-day outcomes.

    PubMed

    Roxbury, Christopher R; Jatana, Kris R; Shah, Rahul K; Boss, Emily F

    2017-02-01

    Prior research has shown that airway reconstructive procedures comprise significant composite morbidity compared to the whole of pediatric otolaryngologic cases evaluated in the American College of Surgeon's National Surgery Quality Improvement Program-Pediatric (ACS-NSQIP-P) platform. We describe postoperative sequelae of pediatric airway reconstructive procedures and identify predictive factors for adverse events. Current procedural terminology (CPT) codes were used to identify children undergoing included procedures in the 2012 to 2014 ACS-NSQIP-P public use files (PUF). Targeted variables included patient demographics and 30-day postoperative events (reoperation, readmission, and complications). Event rates were determined and compared within subgroups. Multivariate logistic regression was performed to identify predictive factors for major adverse events. In 3 years of PUF data (183,283 total cases), 198 cases (0.11%) were airway reconstructive procedures. The most common was laryngoplasty (CPT 31580, 31582; n = 111, 56.1%), followed by cervical tracheoplasty (CPT 31750; n = 47, 23.7%), tracheal resection (CPT 31780; n = 24, 12.1%), and cricoid split (CPT 31587, n = 16, 8.1%). There were 131 premature children (66.2%) and 94 children (47.5%) with history of bronchopulmonary dysplasia. Thirty-day postoperative sequelae included readmissions (n = 42, 21.2%), complications (n = 27, 13.6%), and reoperations (n = 14, 7.1%). On univariate analysis, children less than 3 years of age were more likely to undergo an unplanned reoperation. There were no significant predictive factors for readmission or complication. On multivariate analysis, there was a trend toward higher rates of unplanned reoperations in children less than 3 years of age. The 30-day adverse event rate in pediatric airway surgery is high, with no identifiable predictors noted in the analysis of these data. Findings imply that systematic collection of variables and outcomes specific to pediatric airway

  15. Retuning mortality risk prediction in paediatric cardiac surgery: the additional role of early postoperative metabolic and respiratory profile.

    PubMed

    Ranucci, Marco; Pistuddi, Valeria; Pisani, Giulia Pinuccia; Carlucci, Concetta; Isgrò, Giuseppe; Frigiola, Alessandro; Pomè, Giuseppe; Giamberti, Alessandro

    2016-10-01

    The existing risk stratification scores for paediatric patients undergoing cardiac surgery include the Aristotle Basic Complexity (ABC) Score, the Risk Adjustment in Congenital Heart Surgery-1 (RACHS-1) Score and the Aristotle Comprehensive Complexity (ACC) Score. They are all based on the nature of the surgical operation (ABC and RACHS-1 Scores) with possible adjustment for a number of patient conditions (ACC Score). The present study investigates if the early postoperative parameters may be used to improve the preoperative mortality risk prediction. A retrospective study on 1392 consecutive patients aged ≤12 years old, undergoing cardiac surgery with cardiopulmonary bypass and without a residual right-to-left shunt was conducted. The ABC Score and metabolic and respiratory postoperative parameters at arrival in the intensive care unit were tested for association and discriminative power for operative mortality. The ABC yielded a c-statistic of 0.746. Additional independent predictors of operative mortality were postoperative hypoxia [Formula: see text] and arterial blood lactates. In a multivariable model including the ABC Score, postoperative hypoxia and arterial blood lactates remained independently associated with operative mortality. A modified ABC Score was created, consisting of the ABC Score plus 1.5 points in case of postoperative hypoxia plus 1 point per each 1 mmol/l of arterial blood lactates. The new model was significantly (P = 0.043) more discriminative than the ABC Score, with a c-statistic of 0.803. Early postoperative respiratory and metabolic parameters increased the accuracy and discrimination of the ABC Score. An external validation is needed to confirm our results. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

  16. The American Heart Association's recent scientific statement on cardiac critical care: implications for pediatric practice.

    PubMed

    Penny, Daniel J; Shekerdemian, Lara S

    2013-01-01

    A writing group sponsored by the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, the Council on Clinical Cardiology, the Council on Cardiovascular Nursing, and the Council on Quality of Care and Outcomes Research of The American Heart Association has recently formulated a roadmap to meet the changing needs of the patient with cardiovascular disease requiring critical care. Although this roadmap has been formulated primarily to address the care needs of the adult with critical cardiovascular disease, it contains useful lessons pertinent to the care of the patient with pediatric and congenital cardiovascular disease. In this document, we have examined The Statement and applied its framework to the evolving field of pediatric cardiac critical care.

  17. Prophylactic vacuum sealing drainage (VSD) in the prevention of postoperative surgical site infections in pediatric patients with contaminated laparotomy incisions

    PubMed Central

    Chen, Bailin; Hao, Fabao; Yang, Yang; Shang, Qingjuan; Guo, Chunbao

    2017-01-01

    Abstract Surgical site infection (SSI) continues to be an issue in abdominal surgery, especially for contaminated (class III) and dirty-infected (class IV) wounds. Vacuum sealing drainage (VSD) was reported effective in the management of various types of wounds or skin grafts. Our goal was to investigate the efficacy of prophylactic VSD to better orient their medicosurgical care of high-risk incisions following laparotomy in a pediatric population. A total of 331 pediatric patients with contaminated (class III) and dirty-infected (class IV) wounds following emergency laparotomy were retrospectively reviewed between January 2005 and January 2013. Among them, 111 cases were placed with prophylactic VSD when incisions were closed. Clinical outcomes, including, overall surgical site complication, device effectiveness, and mean postoperative LOS were evaluated based on VSD usage or not. VSD was applied for an average of 5.8 days (range, 5–7 days), with 3 to 15 mL sucked fluid. The overall SSIs rate was 3% for patients with prophylactic VSD and 17% for patients with convention dressing (OR, 0.27; 95% CI, 0.10–0.71, P = 0.004). In patients with prophylactic VSD, only 1 of 96 wound developed postoperative incision dehiscence, which is significant reduced compared with patients for conventional dressings (OR, 0.12; 95% CI, 0.01–0.95; P = 0.017) (Table 2). It also exhibited a decreased mean postoperative LOS (P < 0.001) for prophylactic VSD over conventional dressings. Our study demonstrated beneficial postoperative clinical effects of prophylactic VSD for high-risk laparotomy incisions following emergency laparotomy, such as shorter length of hospitalization, which may be attributed to the reduced overall SSIs rate. PMID:28353606

  18. Prophylactic vacuum sealing drainage (VSD) in the prevention of postoperative surgical site infections in pediatric patients with contaminated laparotomy incisions.

    PubMed

    Chen, Bailin; Hao, Fabao; Yang, Yang; Shang, Qingjuan; Guo, Chunbao

    2017-03-01

    Surgical site infection (SSI) continues to be an issue in abdominal surgery, especially for contaminated (class III) and dirty-infected (class IV) wounds. Vacuum sealing drainage (VSD) was reported effective in the management of various types of wounds or skin grafts. Our goal was to investigate the efficacy of prophylactic VSD to better orient their medicosurgical care of high-risk incisions following laparotomy in a pediatric population.A total of 331 pediatric patients with contaminated (class III) and dirty-infected (class IV) wounds following emergency laparotomy were retrospectively reviewed between January 2005 and January 2013. Among them, 111 cases were placed with prophylactic VSD when incisions were closed. Clinical outcomes, including, overall surgical site complication, device effectiveness, and mean postoperative LOS were evaluated based on VSD usage or not.VSD was applied for an average of 5.8 days (range, 5-7 days), with 3 to 15 mL sucked fluid. The overall SSIs rate was 3% for patients with prophylactic VSD and 17% for patients with convention dressing (OR, 0.27; 95% CI, 0.10-0.71, P = 0.004). In patients with prophylactic VSD, only 1 of 96 wound developed postoperative incision dehiscence, which is significant reduced compared with patients for conventional dressings (OR, 0.12; 95% CI, 0.01-0.95; P = 0.017) (Table 2). It also exhibited a decreased mean postoperative LOS (P < 0.001) for prophylactic VSD over conventional dressings.Our study demonstrated beneficial postoperative clinical effects of prophylactic VSD for high-risk laparotomy incisions following emergency laparotomy, such as shorter length of hospitalization, which may be attributed to the reduced overall SSIs rate.

  19. Improving Prediction of Postoperative Myocardial Infarction With High-Sensitivity Cardiac Troponin T and NT-proBNP.

    PubMed

    Kopec, Michael; Duma, Andreas; Helwani, Mohammad A; Brown, Jamie; Brown, Frank; Gage, Brian F; Gibson, David W; Miller, J Philip; Novak, Eric; Jaffe, Allan S; Apple, Fred S; Scott, Mitchell G; Nagele, Peter

    2017-02-01

    This study sought to determine whether preoperatively measured high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) improve cardiac risk prediction in patients undergoing major noncardiac surgery compared with the standard risk indices. In this ancillary study to the Vitamins in Nitrous Oxide trial, patients were included who had preoperative hs-cTnT and NT-proBNP measured (n = 572). Study outcome was the incidence of postoperative myocardial infarction (MI) within the first 3 postoperative days. hs-cTnT was considered elevated if >14 ng/L and NT-proBNP if >300 ng/L. Additional cutoff values were investigated on the basis of receiver operating characteristic statistics. Biomarker risk prediction was compared with Lee's Revised Cardiac Risk Index (RCRI) with the use of standard methods and net reclassification index. The addition of hs-cTnT (>14 ng/L) and NT-proBNP (>300 ng/L) to RCRI significantly improved the prediction of postoperative MI (event rate 30/572 [5.2%], Area under the receiver operating characteristic curve increased from 0.590 to 0.716 with a 0.66 net reclassification index [95% confidence interval 0.32-0.99], P < .001). The use of 108 ng/L as a cutoff for NT-proBNP improved sensitivity compared with 300 ng/L (0.87 vs 0.53). Sensitivity, specificity, positive, and negative predictive value for hs-cTnT were 0.70, 0.60, 0.09, and 0.97 and for NT-proBNP were 0.53, 0.68, 0.08, and 0.96. The addition of cardiac biomarkers hs-cTnT and NT-proBNP to RCRI improves the prediction of adverse cardiac events in the immediate postoperative period after major noncardiac surgery. The high negative predictive value of preoperative hs-cTnT and NT-proBNP suggest usefulness as a "rule-out" test to confirm low risk of postoperative MI.

  20. Comparative study of postoperative morbidity in dental treatment under general anesthesia in pediatric patients with and without an underlying disease.

    PubMed

    Escanilla-Casal, Alejandro; Ausucua-Ibáñez, Martina; Aznar-Gómez, Mireia; Viaño-García, José M; Sentís-Vilalta, Joan; Rivera-Baró, Alejandro

    2016-03-01

    To identify and quantify the variables and their influence on postoperative morbidity in dental treatment under general anesthesia (GA) in pediatric patients with and without an underlying disease. A prospective, descriptive, and comparative analysis was conducted of healthy (n = 49) and disabled/medically compromised (n = 81) children treated under GA. Intra-/post-surgical, clinical epidemiology, technical, care-related, and pharmacologic data were gathered, as were postoperative complications. The average age of ASA I patients (6.7 ± 4.4 years) was younger than that of ASA II-III patients (9.0 ± 4.5 years). Average hospitalization time was 4.27 ± 6.5 h in ASA I and 7.41 ± 6.8 h in ASA II-III. Significant differences were found between the two groups in fillings, pulpotomies, oral surgery, and scaling. Postoperative morbidity in ASA I and ASA II-III was similar both in frequency and severity and decreased during the first 72 h. The most common complication in both groups was toothache. Postoperative morbidity is high after dental treatment under GA, but it is not higher in disabled/medically compromised patients. © 2015 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

  1. Utilization of cardiac troponin assays in adult and pediatric populations: Guideline recommendations vs. reality.

    PubMed

    Saenger, Amy K; Haymond, Shannon

    2015-12-01

    We hypothesized significant gaps remained for cardiac troponin (cTn) utilization in the United States, despite an emerging evidence base and guideline recommendations. We tested this hypothesis and investigated differences and trends between the use of cTn in adult versus pediatric hospitals. Individuals were identified by a targeted distribution through personal contact and professional society email lists. Participants completed an online survey (Qualtrics) from 07/15/13 to 07/26/13. The 31-item questionnaire used skipped logic and collected data about the respondent and their institutional cTn clinical practices. Data tabulation and analysis were conducted using Qualtrics and Microsoft Excel. A total of 159 unique laboratories responded to the survey, representing primarily adult (81%) versus pediatric (19%) institutions. 59% of laboratories utilize the guideline recommended 99th percentile as the upper reference limit (URL) for cTn, with large variability in reporting practices among users of the same assay. 73% of laboratories reported simultaneous ordering of other cardiac biomarkers with cTn, a majority which included CK-MB. Interpretive comments were used with cTn in 71 laboratories with a significant amount of heterogeneity. Pediatric hospitals reported a lower frequency of cTn orders and were less likely to consider elevated cTn a critical value. Gaps in current utilization and reporting of cTn exist, along with practices inconsistent with clinical guideline recommendations. Implementation of the 99th percentile and serial sampling protocols will be critical to adoption of high-sensitivity cTn assays. Differences in chest pain etiology are the most likely reason for the notable differences between cTn use in adults versus pediatric hospitals. Copyright © 2015 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

  2. Creation and Validation of an Automated Algorithm to Determine Postoperative Ventilator Requirements After Cardiac Surgery.

    PubMed

    Gabel, Eilon; Hofer, Ira S; Satou, Nancy; Grogan, Tristan; Shemin, Richard; Mahajan, Aman; Cannesson, Maxime

    2017-05-01

    In medical practice today, clinical data registries have become a powerful tool for measuring and driving quality improvement, especially among multicenter projects. Registries face the known problem of trying to create dependable and clear metrics from electronic medical records data, which are typically scattered and often based on unreliable data sources. The Society for Thoracic Surgery (STS) is one such example, and it supports manually collected data by trained clinical staff in an effort to obtain the highest-fidelity data possible. As a possible alternative, our team designed an algorithm to test the feasibility of producing computer-derived data for the case of postoperative mechanical ventilation hours. In this article, we study and compare the accuracy of algorithm-derived mechanical ventilation data with manual data extraction. We created a novel algorithm that is able to calculate mechanical ventilation duration for any postoperative patient using raw data from our EPIC electronic medical record. Utilizing nursing documentation of airway devices, documentation of lines, drains, and airways, and respiratory therapist ventilator settings, the algorithm produced results that were then validated against the STS registry. This enabled us to compare our algorithm results with data collected by human chart review. Any discrepancies were then resolved with manual calculation by a research team member. The STS registry contained a total of 439 University of California Los Angeles cardiac cases from April 1, 2013, to March 31, 2014. After excluding 201 patients for not remaining intubated, tracheostomy use, or for having 2 surgeries on the same day, 238 cases met inclusion criteria. Comparing the postoperative ventilation durations between the 2 data sources resulted in 158 (66%) ventilation durations agreeing within 1 hour, indicating a probable correct value for both sources. Among the discrepant cases, the algorithm yielded results that were exclusively

  3. Low cardiac output syndrome in the postoperative period of cardiac surgery. Profile, differences in clinical course and prognosis. The ESBAGA study.

    PubMed

    Pérez Vela, J L; Jiménez Rivera, J J; Alcalá Llorente, M Á; González de Marcos, B; Torrado, H; García Laborda, C; Fernández Zamora, M D; González Fernández, F J; Martín Benítez, J C

    2017-07-20

    An analysis is made of the clinical profile, evolution and differences in morbidity and mortality of low cardiac output syndrome (LCOS) in the postoperative period of cardiac surgery, according to the 3 diagnostic subgroups defined by the SEMICYUC Consensus 2012. A multicenter, prospective cohort study was carried out. ICUs of Spanish hospitals with cardiac surgery. A consecutive sample of 2,070 cardiac surgery patients was included, with the analysis of 137 patients with LCOS. No intervention was carried out. The mean patient age was 68.3±9.3 years (65.2% males), with a EuroSCORE II of 9.99±13. NYHA functional class III-IV (52.9%), left ventricular ejection fraction<35% (33.6%), AMI (31.9%), severe PHT (21.7%), critical preoperative condition (18.8%), prior cardiac surgery (18.1%), PTCA/stent placement (16.7%). According to subgroups, 46 patients fulfilled hemodynamic criteria of LCOS (group A), 50 clinical criteria (group B), and the rest (n=41) presented cardiogenic shock (group C). Significant differences were observed over the evolutive course between the subgroups in terms of time subjected to mechanical ventilation (114.4, 135.4 and 180.3min in groups A, B and C, respectively; P<.001), renal replacement requirements (11.4, 14.6 and 36.6%; P=.007), multiorgan failure (16.7, 13 and 47.5%), and mortality (13.6, 12.5 and 35.9%; P=.01). The mean maximum lactate concentration was higher in cardiogenic shock patients (P=.002). The clinical evolution of these patients leads to high morbidity and mortality. We found differences between the subgroups in terms of the postoperative clinical course and mortality. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

  4. Recombinant activated factor VII for life-threatening pulmonary hemorrhage after pediatric cardiac surgery.

    PubMed

    Leibovitch, Leah; Kenet, Gili; Mazor, Kineret; Matok, Ilan; Vardi, Amir; Barzilay, Zohar; Paret, Gideon

    2003-10-01

    To report intractable life-threatening pulmonary hemorrhage after cardiac surgery in an infant who was treated successfully with recombinant activated factor VII (rFVIIa). Descriptive case report. An 18-bed pediatric intensive care unit at a tertiary-care children's hospital. A 10-wk-old child with acute life-threatening pulmonary hemorrhage after cardiac surgery. General supportive intensive care. Care included mechanical ventilatory support, inotropic support, and concurrent treatment with blood products (packed cells, platelet concentrates, and plasma-derived products), as well as aprotinin and desmopressin to improve hemostasis. The addition of rFVIIa resulted in complete resolution of the hemorrhage. rFVIIa should be considered as a possible novel therapeutic approach to be used as rescue therapy for patients presenting with massive life-threatening hemorrhage progressing into hemorrhagic shock. Further controlled trials to elucidate the safety of this treatment are warranted.

  5. Association between severity of untreated sleep apnoea and postoperative complications following major cardiac surgery: a prospective observational cohort study.

    PubMed

    Mason, Martina; Hernández Sánchez, Jules; Vuylsteke, Alain; Smith, Ian

    2017-09-01

    To examine whether untreated sleep apnoea is associated with prolonged Intensive Care Unit (ICU) stay and increased frequency of postoperative ICU complications, in patients undergoing major cardiac surgery. Adult patients, undergoing elective coronary artery bypass grafting with or without cardiac valve surgery, between March 2013 and July 2014, were considered. We excluded patients participating in other interventional studies, those who had a tracheostomy before surgery, required emergency surgery or were due to be admitted on the day of surgery. Patients underwent inpatient overnight oximetry on the night prior to their surgery to assess for the presence of sleep apnoea. Since oximetry alone cannot differentiate obstructive from central apnoea, the results are reported as sleep apnoea which was diagnosed in patients with an arterial oxygen desaturation index (ODI) ≥ 5/h. The primary outcome measure was length of stay (LoS) in ICU in days. The secondary outcome was a composite measure of postoperative complications in ICU. Multivariate models were developed to assess associations between ODI and the primary and secondary outcome measures, adjusting for preselected predictor variables, relative to primary and secondary outcomes. There was no significant association between ODI and ICU LoS, HR 1.0, 95% CI 0.99-1.02; p = 0.12. However we did find a significant association between ODI and postoperative complications in the ICU, OR = 1.1; 95% CI 1.02-1.17; p = 0.014. The probability of developing complications rose with higher ODI, reflecting sleep apnoea severity. Acknowledging the limitations of this prospective study, untreated sleep apnoea did not predict an increased length of stay in ICU but we do report an association with postoperative complications in patients undergoing major cardiac surgery. Copyright © 2017 Elsevier B.V. All rights reserved.

  6. Simultaneous recordings of intrinsic cardiac nerve activity and skin sympathetic nerve activity from human patients during the postoperative period.

    PubMed

    Shen, Mark J; Coffey, Arthur C; Straka, Susan; Adams, David E; Wagner, David B; Kovacs, Richard J; Clark, Michael; Shen, Changyu; Chen, Lan S; Everett, Thomas H; Lin, Shien-Fong; Chen, Peng-Sheng

    2017-06-23

    Intrinsic cardiac nerve activity (ICNA) and skin nerve activity (SKNA) are both associated with cardiac arrhythmias in dogs. The purpose of this study was to test the hypothesis that ICNA and SKNA correlate with postoperative cardiac arrhythmias in humans. Eleven patients (mean age 60 ± 13 years; 4 women) were enrolled in this study. Electrical signals were simultaneously recorded from electrocardiogram (ECG) patch electrodes on the chest wall and from 2 temporary pacing wires placed during open heart surgery on the left atrial epicardial fat pad. The signals were filtered to display SKNA and ICNA. Premature atrial contractions (PACs) and premature ventricular contractions were determined manually. The SKNA and ICNA of the first 300 minutes of each patient were calculated minute by minute to determine baseline average amplitudes of nerve activities and to determine their correlation with arrhythmia burden. We processed 1365 ± 973 minutes of recording per patient. Low-amplitude SKNA and ICNA were present at all time, while the burst discharges were observed much less frequently. Both SKNA and burst ICNA were significantly associated with the onset of PACs and premature ventricular contractions. Baseline average ICNA (aICNA), but not average SKNA, had a significant association with PAC burden. The correlation coefficient (r) between aICNA and PAC burden was 0.78 (P < .01). A patient with the greatest aICNA developed postoperative atrial fibrillation. ICNA and SKNA can be recorded from human patients in the postoperative period. The baseline magnitude of ICNA correlates with PAC burden and development of postoperative atrial fibrillation. Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  7. Postoperative neurocognitive dysfunction in patients undergoing cardiac surgery after remote ischemic preconditioning: a double-blind randomized controlled pilot study.

    PubMed

    Meybohm, Patrick; Renner, Jochen; Broch, Ole; Caliebe, Dorothee; Albrecht, Martin; Cremer, Jochen; Haake, Nils; Scholz, Jens; Zacharowski, Kai; Bein, Berthold

    2013-01-01

    Remote ischemic preconditioning (RIPC) has been shown to enhance the tolerance of remote organs to cope with a subsequent ischemic event. We hypothesized that RIPC reduces postoperative neurocognitive dysfunction (POCD) in patients undergoing complex cardiac surgery. We conducted a prospective, randomized, double-blind, controlled trial including 180 adult patients undergoing elective cardiac surgery with cardiopulmonary bypass. Patients were randomized either to RIPC or to control group. Primary endpoint was postoperative neurocognitive dysfunction 5-7 days after surgery assessed by a comprehensive test battery. Cognitive change was assumed if the preoperative to postoperative difference in 2 or more tasks assessing different cognitive domains exceeded more than one SD (1 SD criterion) or if the combined Z score was 1.96 or greater (Z score criterion). According to 1 SD criterion, 52% of control and 46% of RIPC patients had cognitive deterioration 5-7 days after surgery (p = 0.753). The summarized Z score showed a trend to more cognitive decline in the control group (2.16±5.30) compared to the RIPC group (1.14±4.02; p = 0.228). Three months after surgery, incidence and severity of neurocognitive dysfunction did not differ between control and RIPC. RIPC tended to decrease postoperative troponin T release at both 12 hours [0.60 (0.19-1.94) µg/L vs. 0.48 (0.07-1.84) µg/L] and 24 hours after surgery [0.36 (0.14-1.89) µg/L vs. 0.26 (0.07-0.90) µg/L]. We failed to demonstrate efficacy of a RIPC protocol with respect to incidence and severity of POCD and secondary outcome variables in patients undergoing a wide range of cardiac surgery. Therefore, definitive large-scale multicenter trials are needed. ClinicalTrials.gov NCT00877305.

  8. Significant correlation of comprehensive Aristotle score with total cardiac output during the early postoperative period after the Norwood procedure.

    PubMed

    Li, Jia; Zhang, Gencheng; Holtby, Helen; Cai, Sally; Walsh, Mark; Caldarone, Christopher A; Van Arsdell, Glen S

    2008-07-01

    The comprehensive Aristotle score has been proposed as an individualized measure of the complexity of a given surgical procedure and has been reported to significantly correlate with postoperative morbidity and mortality after the Norwood procedure. An important factor leading to postoperative morbidity and mortality is low cardiac output. We studied the correlation between the comprehensive Aristotle score and cardiac output (CO) in infants after the Norwood procedure. Respiratory mass spectrometry was used to continuously measure systemic oxygen consumption (VO(2)) in 22 infants for 72 hours postoperatively. Arterial, superior vena caval and pulmonary venous blood gases were measured at 2 to 4 hour intervals to calculate CO. The comprehensive Aristotle score was collected. Hospital mortality was 4.5%. The comprehensive Aristotle score ranged from 14.5 to 23.5 and negatively correlated with CO (P = 0.027). Among the patient-adjusted factors, myocardial dysfunction (n = 10), mechanical ventilation to treat cardiorespiratory failure (n = 9) and atrioventricular valve regurgitation (n = 4) (P = 0.01) negatively correlated with CO (P = 0.06 to 0.07). Aortic atresia (n = 9) was associated with a lower CO (P = 0.01) for the first 24 hours which linearly increased overtime (P = 0.0001). No correlation was found between CO and other factors (P > 0.3 for all). Comprehensive Aristotle score significantly negatively correlates with CO after the Norwood procedure. A preoperative estimation of the comprehensive Aristotle score, particularly in association with myocardial dysfunction, mechanical ventilation to treat cardiorespiratory failure, atrioventricular valve regurgitation and aortic atresia may help to anticipate a high postoperative morbidity with low cardiac output syndrome.

  9. Predicted risks of radiogenic cardiac toxicity in two pediatric patients undergoing photon or proton radiotherapy.

    PubMed

    Zhang, Rui; Howell, Rebecca M; Homann, Kenneth; Giebeler, Annelise; Taddei, Phillip J; Mahajan, Anita; Newhauser, Wayne D

    2013-07-23

    Hodgkin disease (HD) and medulloblastoma (MB) are common malignancies found in children and young adults, and radiotherapy is part of the standard treatment. It was reported that these patients who received radiation therapy have an increased risk of cardiovascular late effects. We compared the predicted risk of developing radiogenic cardiac toxicity after photon versus proton radiotherapies for a pediatric patient with HD and a pediatric patient with MB. In the treatment plans, each patient's heart was contoured in fine detail, including substructures of the pericardium and myocardium. Risk calculations took into account both therapeutic and stray radiation doses. We calculated the relative risk (RR) of cardiac toxicity using a linear risk model and the normal tissue complication probability (NTCP) values using relative seriality and Lyman models. Uncertainty analyses were also performed. The RR values of cardiac toxicity for the HD patient were 7.27 (proton) and 8.37 (photon), respectively; the RR values for the MB patient were 1.28 (proton) and 8.39 (photon), respectively. The predicted NTCP values for the HD patient were 2.17% (proton) and 2.67% (photon) for the myocardium, and were 2.11% (proton) and 1.92% (photon) for the whole heart. The predicted ratios of NTCP values (proton/photon) for the MB patient were much less than unity. Uncertainty analyses revealed that the predicted ratio of risk between proton and photon therapies was sensitive to uncertainties in the NTCP model parameters and the mean radiation weighting factor for neutrons, but was not sensitive to heart structure contours. The qualitative findings of the study were not sensitive to uncertainties in these factors. We conclude that proton and photon radiotherapies confer similar predicted risks of cardiac toxicity for the HD patient in this study, and that proton therapy reduced the predicted risk for the MB patient in this study.

  10. Pediatric cardiac arrest due to drowning and other respiratory etiologies: Neurobehavioral outcomes in initially comatose children.

    PubMed

    Slomine, Beth S; Nadkarni, Vinay M; Christensen, James R; Silverstein, Faye S; Telford, Russell; Topjian, Alexis; Koch, Joshua D; Sweney, Jill; Fink, Ericka L; Mathur, Mudit; Holubkov, Richard; Dean, J Michael; Moler, Frank W

    2017-06-01

    To describe the 1-year neurobehavioral outcome of survivors of cardiac arrest secondary to drowning, compared with other respiratory etiologies, in children enrolled in the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital (THAPCA-OH) trial. Exploratory analysis of survivors (ages 1-18 years) who received chest compressions for ≥2min, were comatose, and required mechanical ventilation after return of circulation (ROC). Participants recruited from 27 pediatric intensive care units in North America received targeted temperature management [therapeutic hypothermia (33°C) or therapeutic normothermia (36.8°C)] within 6h of ROC. Neurobehavioral outcomes included 1-year Vineland Adaptive Behavior Scales, Second Edition (VABS-II) total and domain scores and age-appropriate cognitive performance measures (Mullen Scales of Early Learning or Wechsler Abbreviated Scale of Intelligence). Sixty-six children with a respiratory etiology of cardiac arrest survived for 1-year; 60/66 had broadly normal premorbid functioning (VABS-II≥70). Follow up was obtained on 59/60 (30 with drowning etiology). VABS-II composite and domain scores declined significantly from premorbid scores in drowning and non-drowning groups (p<0.001), although declines were less pronounced for the drowning group. Seventy-two percent of children had well below average cognitive functioning at 1-year. Younger age, fewer doses of epinephrine, and drowning etiology were associated with better VABS-II composite scores. Demographic variables and treatment with hypothermia did not influence neurobehavioral outcomes. Risks for poor neurobehavioral outcomes were high for children who were comatose after out-of-hospital cardiac arrest due to respiratory etiologies; survivors of drowning had better outcomes than those with other respiratory etiologies. Copyright © 2017 Elsevier B.V. All rights reserved.

  11. Comparison of Segmental Versus Longitudinal Intravascular Ultrasound Analysis for Pediatric Cardiac Allograft Vasculopathy.

    PubMed

    Kuhn, M A; Burch, M; Chinnock, R E; Fenton, M J

    2017-10-01

    Intravascular ultrasound (IVUS) has been routinely used in some centers to investigate cardiac allograft vasculopathy in pediatric heart transplant recipients. We present an alternative method using more sophisticated imaging software. This study presents a comparison of this method with an established standard method. All patients who had IVUS performed in 2014 were retrospectively evaluated. The standard technique consisted of analysis of 10 operator-selected segments along the vessel. Each study was re-evaluated using a longitudinal technique, taken at every third cardiac cycle, along the entire vessel. Semiautomatic edge detection software was used to detect vessel imaging planes. Measurements included outer and inner diameter, total and luminal area, maximal intimal thickness (MIT), and intimal index. Each IVUS was graded for severity using the Stanford classification. All results were given as mean ± standard deviation (SD). Groups were compared using Student t test. A P value <.05 was considered significant. There were 59 IVUS studies performed on 58 patients. There was no statistically significant difference between outer diameter, inner diameter, or total area. In the longitudinal group, there was a significantly smaller luminal area, higher MIT, and higher intimal index. Using the longitudinal technique, there was an increase in Stanford classification in 20 patients. The longitudinal technique appeared more sensitive in assessing the degree of cardiac allograft vasculopathy and may play a role in the increase in the degree of thickening seen. It may offer an alternative way of grading severity of cardiac allograft vasculopathy in pediatric heart transplant recipients. Copyright © 2017 Elsevier Inc. All rights reserved.

  12. Predicted risks of radiogenic cardiac toxicity in two pediatric patients undergoing photon or proton radiotherapy

    PubMed Central

    2013-01-01

    Background Hodgkin disease (HD) and medulloblastoma (MB) are common malignancies found in children and young adults, and radiotherapy is part of the standard treatment. It was reported that these patients who received radiation therapy have an increased risk of cardiovascular late effects. We compared the predicted risk of developing radiogenic cardiac toxicity after photon versus proton radiotherapies for a pediatric patient with HD and a pediatric patient with MB. Methods In the treatment plans, each patient’s heart was contoured in fine detail, including substructures of the pericardium and myocardium. Risk calculations took into account both therapeutic and stray radiation doses. We calculated the relative risk (RR) of cardiac toxicity using a linear risk model and the normal tissue complication probability (NTCP) values using relative seriality and Lyman models. Uncertainty analyses were also performed. Results The RR values of cardiac toxicity for the HD patient were 7.27 (proton) and 8.37 (photon), respectively; the RR values for the MB patient were 1.28 (proton) and 8.39 (photon), respectively. The predicted NTCP values for the HD patient were 2.17% (proton) and 2.67% (photon) for the myocardium, and were 2.11% (proton) and 1.92% (photon) for the whole heart. The predicted ratios of NTCP values (proton/photon) for the MB patient were much less than unity. Uncertainty analyses revealed that the predicted ratio of risk between proton and photon therapies was sensitive to uncertainties in the NTCP model parameters and the mean radiation weighting factor for neutrons, but was not sensitive to heart structure contours. The qualitative findings of the study were not sensitive to uncertainties in these factors. Conclusions We conclude that proton and photon radiotherapies confer similar predicted risks of cardiac toxicity for the HD patient in this study, and that proton therapy reduced the predicted risk for the MB patient in this study. PMID:23880421

  13. Sustainability of protocolized handover of pediatric cardiac surgery patients to the intensive care unit.

    PubMed

    Chenault, Kristin; Moga, Michael-Alice; Shin, Minah; Petersen, Emily; Backer, Carl; De Oliveira, Gildasio S; Suresh, Santhanam

    2016-05-01

    Transfer of patient care among clinicians (handovers) is a common source of medical errors. While the immediate efficacy of these initiatives is well documented, sustainability of practice changes that results in better processes of care is largely understudied. The objective of the current investigation was to evaluate the sustainability of a protocolized handover process in pediatric patients from the operating room after cardiac surgery to the intensive care unit. This was a prospective study with direct observation assessment of handover performance conducted in the cardiac ICU (CICU) of a free-standing, tertiary care children's hospital in the United States. Patient transitions from the operating room to the CICU, including the verbal handoff, were directly observed by a single independent observer in all phases of the study. A checklist of key elements identified errors classified as: (1) technical, (2) information omissions, and (3) realized errors. Total number of errors was compared across the different times of the study (preintervention, postintervention, and the current sustainability phase). A total of 119 handovers were studied: 41 preintervention, 38 postintervention, and 40 in the current sustainability phase. The median [Interquartile range (IQR)] number of technical errors was significantly reduced in the sustainability phase compared to the preintervention and postintervention phase, 2 (1-3), 6 (5-7), and 2.5 (2-4), respectively P = 0.0001. Similarly, the median (IQR) number of verbal information omissions was also significantly reduced in the sustainability phase compared to the preintervention and postintervention phases, 1 (1-1), 4 (3-5) and 2 (1-3), respectively. We demonstrate sustainability of an improved handover process using a checklist in children being transferred to the intensive care unit after cardiac surgery. Standardized handover processes can be a sustainable strategy to improve patient safety after pediatric cardiac surgery.

  14. Early Head CT Findings Are Associated With Outcomes After Pediatric Out-of-Hospital Cardiac Arrest

    PubMed Central

    Starling, Rebecca M.; Shekdar, Karuna; Licht, Dan; Nadkarni, Vinay M.; Berg, Robert A.; Topjian, Alexis A.

    2015-01-01

    Objectives Head CT after out-of-hospital cardiac arrest is often obtained to evaluate intracranial pathology. Among children admitted to the PICU following pediatric out-of-hospital cardiac arrest, we hypothesized that loss of gray-white matter differentiation and basilar cistern and sulcal effacement are associated with mortality and unfavorable neurologic outcome. Design Retrospective, cohort study. Setting Single, tertiary-care center PICU. Patients Seventy-eight patients less than 18 years old who survived out-of-hospital cardiac arrest to PICU admission and had a head CT within 24 hours of return of spontaneous circulation were evaluated from July 2005 through May 2012. Interventions None. Measurements and Main Results Median time to head CT from return of spontaneous circulation was 3.3 hours (1.0, 6.0). Median patient age was 2.3 years (0.4, 9.5). Thirty-nine patients (50%) survived, of whom 29 (74%) had favorable neurologic outcome. Nonsurvivors were more likely than survivors to have 1) loss of gray-white matter differentiation (Hounsfield unit ratios, 0.96 [0.88, 1.07] vs 1.1 [1.07, 1.2]; p < 0.001), 2) basilar cistern effacement (93% vs 7%; p = 0.001; positive predictive value, 94%; negative predictive value, 59%), and 3) sulcal effacement (100% vs 0%; p ≤ 0.001; positive predictive value, 100%; negative predictive value, 68%). All patients with poor gray-white matter differentiation or sulcal effacement had unfavorable neurologic outcomes. Only one patient with basilar cistern effacement had favorable outcome. Conclusions Loss of gray-white matter differentiation and basilar cistern effacement and sulcal effacement are associated with poor outcome after pediatric out-of-hospital cardiac arrest. Select patients may have favorable outcomes despite these findings. PMID:25844694

  15. Early Head CT Findings Are Associated With Outcomes After Pediatric Out-of-Hospital Cardiac Arrest.

    PubMed

    Starling, Rebecca M; Shekdar, Karuna; Licht, Dan; Nadkarni, Vinay M; Berg, Robert A; Topjian, Alexis A

    2015-07-01

    Head CT after out-of-hospital cardiac arrest is often obtained to evaluate intracranial pathology. Among children admitted to the PICU following pediatric out-of-hospital cardiac arrest, we hypothesized that loss of gray-white matter differentiation and basilar cistern and sulcal effacement are associated with mortality and unfavorable neurologic outcome. Retrospective, cohort study. Single, tertiary-care center PICU. Seventy-eight patients less than 18 years old who survived out-of-hospital cardiac arrest to PICU admission and had a head CT within 24 hours of return of spontaneous circulation were evaluated from July 2005 through May 2012. None. Median time to head CT from return of spontaneous circulation was 3.3 hours (1.0, 6.0). Median patient age was 2.3 years (0.4, 9.5). Thirty-nine patients (50%) survived, of whom 29 (74%) had favorable neurologic outcome. Nonsurvivors were more likely than survivors to have 1) loss of gray-white matter differentiation (Hounsfield unit ratios, 0.96 [0.88, 1.07] vs 1.1 [1.07, 1.2]; p < 0.001), 2) basilar cistern effacement (93% vs 7%; p = 0.001; positive predictive value, 94%; negative predictive value, 59%), and 3) sulcal effacement (100% vs 0%; p ≤ 0.001; positive predictive value, 100%; negative predictive value, 68%). All patients with poor gray-white matter differentiation or sulcal effacement had unfavorable neurologic outcomes. Only one patient with basilar cistern effacement had favorable outcome. Loss of gray-white matter differentiation and basilar cistern effacement and sulcal effacement are associated with poor outcome after pediatric out-of-hospital cardiac arrest. Select patients may have favorable outcomes despite these findings.

  16. Correlation of the EuroSCORE with the onset of postoperative acute kidney injury in cardiac surgery

    PubMed Central

    de Moura, Edmilson Bastos; Bernardes Neto, Saint-Clair Gomes; Amorim, Fábio Ferreira; Viscardi, Renato Camargo

    2013-01-01

    Objective The objective of this study was to assess the correlation between the European System for Cardiac Operative Risk Evaluation (EuroSCORE) score and the risk of developing acute kidney injury in cardiac surgery patients. Methods This retrospective study was conducted at a tertiary hospital on consecutive cardiac surgery patients (e.g., valvular, ischemic and congenital heart diseases) between October 2010 and July 2011. Results One hundred patients were assessed. Among the 100 patients, six were excluded, including five because of prior kidney disease or dialysis therapy and one because of incomplete medical records. The primary surgical indications were myocardial revascularization in 55 patients (58.5% of cases) and valve replacement in 28 patients (29.8%). According to the EuroSCORE, 55 patients were classified as high risk (58.5%), 27 patients as medium risk (28.7%) and 12 patients as low risk (12.8%). In the postoperative period, patients were classified with the Risk, Injury, Failure, Loss and End-stage kidney disease (RIFLE) score. Among the 31 patients (33%) who displayed an increase in serum creatinine, 18 patients (19.1%) were classified as RIFLE "R" (risk), seven patients (7.4%) were classified as RIFLE "I" (injury) and six patients (6.5%) were classified as RIFLE "F" (failure). Among the patients who were considered to be high risk according to the EuroSCORE criteria, 24 patients (43.6%) showed acute kidney injury. Among the patients who were classified as medium or low risk, acute kidney injury occurred in 18.5 and 16.6% of the cases, respectively. The correlations between risk stratification (low, medium and high) and the EuroSCORE and postoperative RIFLE scores were statistically significant (p=0.03). Conclusion In the studied population, there was a statistically significant correlation between the EuroSCORE and the risk of developing acute kidney injury in the postoperative period after cardiac surgery. PMID:24213087

  17. Direct measurement of a patient's entrance skin dose during pediatric cardiac catheterization

    PubMed Central

    Sun, Lue; Mizuno, Yusuke; Iwamoto, Mari; Goto, Takahisa; Koguchi, Yasuhiro; Miyamoto, Yuka; Tsuboi, Koji; Chida, Koichi; Moritake, Takashi

    2014-01-01

    Children with complex congenital heart diseases often require repeated cardiac catheterization; however, children are more radiosensitive than adults. Therefore, radiation-induced carcinogenesis is an important consideration for children who undergo those procedures. We measured entrance skin doses (ESDs) using radio-photoluminescence dosimeter (RPLD) chips during cardiac catheterization for 15 pediatric patients (median age, 1.92 years; males, n = 9; females, n = 6) with cardiac diseases. Four RPLD chips were placed on the patient's posterior and right side of the chest. Correlations between maximum ESD and dose–area products (DAP), total number of frames, total fluoroscopic time, number of cine runs, cumulative dose at the interventional reference point (IRP), body weight, chest thickness, and height were analyzed. The maximum ESD was 80 ± 59 (mean ± standard deviation) mGy. Maximum ESD closely correlated with both DAP (r = 0.78) and cumulative dose at the IRP (r = 0.82). Maximum ESD for coiling and ballooning tended to be higher than that for ablation, balloon atrial septostomy, and diagnostic procedures. In conclusion, we directly measured ESD using RPLD chips and found that maximum ESD could be estimated in real-time using angiographic parameters, such as DAP and cumulative dose at the IRP. Children requiring repeated catheterizations would be exposed to high radiation levels throughout their lives, although treatment influences radiation dose. Therefore, the radiation dose associated with individual cardiac catheterizations should be analyzed, and the effects of radiation throughout the lives of such patients should be followed. PMID:24968708

  18. Pediatric Dilated Cardiomyopathy Patients Do Not Meet Traditional Cardiac Resynchronization Criteria.

    PubMed

    Schiller, Ofer; Dham, Niti; Greene, E Anne; Heath, Deneen M; Alexander, Mark E; Berul, Charles I

    2015-08-01

    Cardiac resynchronization therapy (CRT) is an effective device-based intervention for adults with heart failure (HF) with specific indications, based on large, multicenter randomized clinical trials. The criteria for CRT in adult HF include significant symptoms, ventricular systolic dysfunction, prolonged QRS duration, and left bundle branch block (LBBB) pattern on electrocardiogram (ECG). Despite having less data, CRT is also being widely utilized in children with HF. The shortage of evidence-based CRT criteria in pediatrics prompted us to review a cohort of children with dilated cardiomyopathy and evaluate their potential eligibility for CRT using the traditional adult criteria. Single-center data of all pediatric patients with dilated cardiomyopathy were extracted from the heart failure registry and retrospectively reviewed. Patients who had at least 2 separate visits that included HF scoring, electrocardiogram, and echocardiogram were included. Patients who were ventricular paced were excluded. Data for 52 patients meeting inclusion criteria were analyzed. The mean ejection fraction was 25% on the first clinical evaluation and 27% on the second visit. No patient and 2 patients met the adult criteria for prolonged QRS on the first and second encounters, respectively. No patients had an LBBB pattern on ECG. None of the pediatric HF patients in our study met the published Class I criteria for CRT device therapy in adults. These findings suggest that extrapolation of adult HF data to pediatrics is not sufficient for CRT criteria. Specific guidelines for device implantation in children must be based on scientific investigation including pediatric clinical trials. © 2015 Wiley Periodicals, Inc.

  19. Heparin-coated extracorporeal circulation in combination with low dose systemic heparinization reduces early postoperative blood loss in cardiac surgery.

    PubMed

    Mirow, N; Zittermann, A; Koertke, H; Maleszka, A; Knobl, H; Coskun, T; Kleesiek, K; Koerfer, R

    2008-04-01

    According to a recently performed meta-analysis, heparin-bonded circuits do not reduce blood loss in cardiac surgery patients compared to nonheparin-bonded circuits within the first 24 h postoperatively. We investigated the effects of heparin-coated circuits in combination with a reduced systemic heparin dose on early postoperative blood loss (first 12 h), platelet function, and postoperative complications. Patients who underwent their first coronary artery bypass graft surgery were included in a randomized prospective study. Group A (n=149) was perfused with an uncoated extracorporeal circulation (ECC)-set and groups B (n=152) and C (n=149) with heparin-coated ECC-sets. In groups A and B, conventional dose systemic heparin was given, whereas group C received low dose systemic heparin. Blood loss was assessed within the first 12 h postoperatively. Moreover, biochemical parameters of pro-coagulant activity and immunological function were measured. None of the pro-coagulant activity markers and immunological parameters measured differed preoperatively or postoperatively between study groups. However, intraoperative platelet counts and maximal intraoperative concentrations of platelet factor 4, ss-thromboglobulin, and poly-morpho-nuclear (PMN)-elastase were lowest in group C, whereas group C also had the highest concentrations of thrombin-antithrombin complex (P<0.018-0.001). Blood loss within the first 12 h postoperatively was 457 +/- 204 mL in group A, 431 +/- 178 mL in group B, and 382 +/- 188 mL in group C (P<0.01). Complication rates and 30-day mortality did not differ between study groups. The combined use of heparin-coated circuits and low dose systemic heparinization is able to reduce early postoperative blood loss without enhancing the risk of complications.

  20. Contrast-enhanced ultrasound with SonoVue in the evaluation of postoperative complications in pediatric liver transplant recipients

    PubMed Central

    Bonini, G.; Pezzotta, G.; Morzenti, C.; Agazzi, R.; Nani, R.

    2007-01-01

    Purpose To evaluate the utility of contrast-enhanced sonography in the study of pediatric liver transplant recipients and its potential impact in reducing the need for invasive diagnostic procedures. Materials and methods From October 2002 to December 2003 we performed routine color Doppler ultrasound and contrast-enhanced ultrasound studies on 30 pediatric patients who had undergone liver transplantation. Findings indicative of complications were confirmed with invasive studies (angiography, computed tomography, and PTC). Results Contrast-enhanced sonography correctly identified four of the five cases of hepatic artery thrombosis and all those involving the portal (n = 6) and hepatic vein (n = 3) thrombosis. It failed to identify one case of hepatic artery thrombosis characterized by collateral circulation arising from the phrenic artery and the single case of hepatic artery stenosis. The latter was more evident on color Doppler, which revealed a typical tardus parvus waveform. The use of contrast offered no significant advantages in the study of biliary complications although it did provide better visualization of bile leaks. Conclusions Contrast-enhanced sonography improves diagnostic confidence and reduces the need for more invasive imaging studies in the postoperative follow-up of pediatric liver transplant recipients. PMID:23396596

  1. Cardiovascular risk factors and cardiac disorders in long-term survivors of pediatric liver transplantation.

    PubMed

    Baskar, Shankar; George, Peggy L; Eghtesad, Bijan; Radhakrishnan, Kadakkal; Hupertz, Vera; Aziz, Peter F; Alkhouri, Naim

    2015-02-01

    The MetS and cardiovascular disease are leading causes of late morbidity in adult liver transplantation recipients; however, limited data are available in pediatric liver transplantation. A single-center retrospective review was undertaken for patients who had a liver transplantation before 18 yr of age and were >5 yr post-transplantation, to study the prevalence of MetS, its components, and cardiac disorders. Fifty-eight patients were included in the study with a mean age at transplantation of 6.3 ± 6.1 yr and mean follow-up of 14.1 ± 6.0 yr. Of the study group, 41.4% were overweight or obese, with ongoing prednisone use and increased duration of follow-up being significant risk factors. Fifty-three patients had sufficient data for determining MetS, which was present in 17% of the patients. Although the prevalence of MetS is low in pediatric liver transplant recipients, it is associated with CKD and prednisone therapy (p < 0.05). Echocardiography data were available for 23 patients, of whom 43.4% had LVH and 13% had evidence of PH. The spectrum of cardiac disorders in this population is much wider than in adults. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

  2. Prediction of early postoperative infections in pediatric liver transplantation by logistic regression

    NASA Astrophysics Data System (ADS)

    Uzunova, Yordanka; Prodanova, Krasimira; Spassov, Lubomir

    2016-12-01

    Orthotopic liver transplantation (OLT) is the only curative treatment for end-stage liver disease. Early diagnosis and treatment of infections after OLT are usually associated with improved outcomes. This study's objective is to identify reliable factors that can predict postoperative infectious morbidity. 27 children were included in the analysis. They underwent liver transplantation in our department. The correlation between two parameters (the level of blood glucose at 5th postoperative day and the duration of the anhepatic phase) and postoperative infections was analyzed, using univariate analysis. In this analysis, an independent predictive factor was derived which adequately identifies patients at risk of infectious complications after a liver transplantation.

  3. Postoperative Acute Kidney Injury and Blood Product Transfusion After Synthetic Colloid Use During Cardiac Surgery.

    PubMed

    Tobey, Rajika; Cheng, Hao; Gao, Mei; Li, Zhongmin; Young, J Nilas; Boyd, W Douglas; Ji, Fuhai; Liu, Hong

    2017-06-01

    This study assessed the effect of 2 types of hydroxyethyl starches (HES) on renal integrity and blood transfusion in cardiac surgery patients. Retrospective investigation. Patients from a single tertiary medical center. Inclusion criteria included coronary artery bypass graft (CABG) and/or valve surgery that included cardiopulmonary bypass with aortic cross-clamping. Intraoperative HES and blood product administration. The study comprised 1,265 patients who met inclusion criteria. Of these patients, 70% received HES, and of these, 47% received<1,000 mL and 53% received≥1,000 mL. There was no difference in the development of acute kidney injury between the 2 groups. A parsimonious propensity model for colloids showed that combined CABG and valve surgery were less likely to be associated with HES administration than was CABG alone (OR 0.68, confidence interval [CI] 0.46-0.97; p = 0.04). Intra-aortic balloon pump use was less likely to be associated with HES administration (OR 0.57, CI 0.38-0.86; p = 0.007). Patients with chronic kidney disease, stages 3 to 5, were less likely to receive HES, with an OR of 0.56 (CI 0.38-0.84; p = 0.004); 0.51 (CI 0.20-1.33; p = 0.170); and 0.23 (CI 0.12-0.44; p<0.0001), respectively, for each stage. No difference was noted in red blood cell transfusion. However, fresh frozen plasma, cryoprecipitate, and platelet transfusions were significantly higher with larger volumes of HES, with an OR of 2.03 (CI 1.64-2.52; p<0.001); 1.60 (CI 1.30-1.97; p<0.000); and 1.62 (CI 1.21-2.15; p = 0.006), respectively. No differences in surgical mortality were found between the colloid and noncolloid groups. This study showed no association of postoperative acute kidney injury and red blood cell transfusion between the colloid and noncolloid groups. Although the complication rate was higher with HES administration, there was no difference in surgery mortality between the 2 groups. Copyright © 2017 Elsevier Inc. All rights reserved.

  4. Targeted Temperature Management After Pediatric Cardiac Arrest Due To Drowning: Outcomes and Complications

    PubMed Central

    Moler, Frank W.; Hutchison, Jamie S.; Nadkarni, Vinay M.; Silverstein, Faye S.; Meert, Kathleen L.; Holubkov, Richard; Page, Kent; Slomine, Beth S.; Christensen, James R.; Dean, J. Michael

    2016-01-01

    Objective To describe outcomes and complications in the drowning subgroup from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital (THAPCA-OH) Trial. Design Exploratory post hoc cohort analysis Setting Twenty-four PICUs Patients Pediatric drowning cases Interventions Therapeutic hypothermia versus therapeutic normothermia Measurements and Main Results An exploratory study of pediatric drowning from the THAPCA-OH Trial was conducted. Comatose patients >2 days and <18 years were randomized ≤6 hours following return-of-circulation to hypothermia (n=46) or normothermia (n=28). Outcomes assessed included 12-month survival with a Vineland Adaptive Behavior Scale (VABS-II) score ≥70, 1-year survival rate, change in VABS-II score pre-arrest to 12-months, and select safety measures. Seventy-four drowning cases were randomized. In patients with pre-arrest VABS-II ≥70 (n=65), there was no difference in 12-month survival with VABS-II score ≥70 between hypothermia and normothermia groups [29% vs. 17%; relative risk (RR) 1.74; 95% confidence interval (CI) 0.61 to 4.95; p=0.27]. Among all evaluable patients (n=68), the VABS-II score change from baseline to 12-months did not differ (p=0.46) and one-year survival was similar (49%, hypothermia vs. 42%, normothermia; RR 1.16; 95% CI 0.68 to 1.99; p=0.58). Hypothermia was associated with a higher incidence of positive bacterial culture (any blood, urine or respiratory sample) (67% vs. 43%; p=0.04), however, the rate per 100 days at risk did not differ (11.1 vs. 8.4; p=0.46). Cumulative incidence of blood product use, serious arrhythmias and 28-day mortality were not different. Among patients with CPR durations >30 minutes or epinephrine doses >4, none had favorable Pediatric Cerebral Performance Category (PCPC) outcomes (≤3). Conclusions In comatose survivors of out-of-hospital pediatric cardiac arrest due to drowning, hypothermia did not result in a statistically significant benefit in survival with

  5. Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Pulmonary Hypertension.

    PubMed

    Kim, John S; McSweeney, Julia; Lee, Joanne; Ivy, Dunbar

    2016-03-01

    To review the pharmacologic treatment options for pulmonary arterial hypertension in the cardiac intensive care setting and summarize the most-recent literature supporting these therapies. Literature search for prospective studies, retrospective analyses, and case reports evaluating the safety and efficacy of pulmonary arterial hypertension therapies. Mechanisms of action and pharmacokinetics, treatment recommendations, safety considerations, and outcomes for specific medical therapies. Specific targeted therapies developed for the treatment of adult patients with pulmonary arterial hypertension have been applied for the benefit of children with pulmonary arterial hypertension. With the exception of inhaled nitric oxide, there are no pulmonary arterial hypertension medications approved for children in the United States by the Food and Drug Administration. Unfortunately, data on treatment strategies in children with pulmonary arterial hypertension are limited by the small number of randomized controlled clinical trials evaluating the safety and efficacy of specific treatments. The treatment options for pulmonary arterial hypertension in children focus on endothelial-based pathways. Calcium channel blockers are recommended for use in a very small, select group of children who are responsive to vasoreactivity testing at cardiac catheterization. Phosphodiesterase type 5 inhibitor therapy is the most-commonly recommended oral treatment option in children with pulmonary arterial hypertension. Prostacyclins provide adjunctive therapy for the treatment of pulmonary arterial hypertension as infusions (IV and subcutaneous) and inhalation agents. Inhaled nitric oxide is the first-line vasodilator therapy in persistent pulmonary hypertension of the newborn and is commonly used in the treatment of pulmonary arterial hypertension in the ICU. Endothelin receptor antagonists have been shown to improve exercise tolerance and survival in adult patients with pulmonary arterial

  6. Functional Outcome Trajectories after Out-of Hospital Pediatric Cardiac Arrest

    PubMed Central

    Silverstein, Faye S; Slomine, Beth; Christensen, James; Holubkov, Richard; Page, Kent; Dean, J. Michael; Moler, Frank

    2016-01-01

    Objective To analyze functional performance measures collected prospectively during the conduct of a clinical trial that enrolled children (up to age 18 years), resuscitated after out-of-hospital cardiac arrest, who were at high risk for poor outcomes. Design Children with Glasgow Motor Scales <5, within 6 hours of resuscitation, were enrolled in a clinical trial that compared two targeted temperature management interventions (THAPCA-OH, NCT00878644). The primary outcome, 12-month survival with Vineland Adaptive Behavior Scales, second edition (VABS-II) score ≥70, did not differ between groups. Setting 38 North American pediatric ICU’s. Participants 295 children were enrolled; 270/295 had baseline VABS-II scores ≥70; 87/270 survived one year. Interventions Targeted temperatures were 33.0°C and 36.8°C for hypothermia and normothermia groups. Measurements and Main Results Baseline measures included VABS-II, Pediatric Cerebral Performance Category(PCPC), and Pediatric Overall Performance Category (POPC). PCPC and POPC were rescored at hospital discharges; all three were scored at 3 and 12 months. In survivors with baseline VABS-II scores ≥70, we evaluated relationships of hospital discharge PCPC with 3 and 12 month scores, and between 3 and 12 month VABS-II scores. Hospital discharge PCPC scores strongly predicted 3 and 12 month PCPC (r=0.82,0.79; p<0.0001) and VABS-II scores (r=−0.81,−0.77; p<0.0001) Three month VABS-II scores strongly predicted 12 month performance (r=0.95, p<0.0001). Hypothermia treatment did not alter these relationships. Conclusions In comatose children, with Glasgow Motor Scales <5 in the initial hours after out-of-hospital cardiac arrest resuscitation, function scores at hospital discharge and at 3 months predicted 12-month performance well in the majority of survivors. PMID:27509385

  7. Characterization of Cardiac Troponin Elevation in the Setting of Pediatric Supraventricular Tachycardia.

    PubMed

    Moore, Jeremy P; Arcilla, Lisa; Wang, Shuo; Lee, Michael S; Shannon, Kevin M

    2016-02-01

    Cardiac troponin (cTn) is currently considered the gold standard biomarker for detection of myocardial necrosis. Patients with supraventricular tachycardia (SVT) often present with symptoms resulting in cTn assessment; however, there are no data on the results of such testing in childhood. We hypothesized that cTn elevation would be common in the pediatric SVT population and would portend a benign prognosis. A retrospective review of all pediatric patients (≤21 years) presenting with SVT was performed. Clinical and electrocardiographic variables from the emergency department (ED) presentation were reviewed and clinical outcomes during subsequent follow-up assessed. Of 128 patients seen in the ED for SVT, cTn was assessed in 48 (38 %). Of patients with cTn assessment, 14 (29 %) patients demonstrated cTn elevation. Univariate predictors of cTn elevation included presentation with respiratory or gastrointestinal symptoms (50 vs 12 % and 42 vs 9 %; p = 0.008 and p = 0.01, respectively), lower mean arterial blood pressure (73 vs 85 mm Hg, p = 0.009), higher age-adjusted tachycardia rate (z score 9.3 vs 7.2, p < 0.001), and longer tachycardia duration (4.2 vs 1.0 h, p = 0.02). Multivariate logistic regression confirmed the association of age-adjusted tachycardia rate (odds ratio [OR] 3.8 per heart rate z score, confidence interval [CI] 1.9-11.8, p = 0.003) and duration (OR 1.5 per hour, CI 1.1-2.5, p = 0.03). Clinical outcome was excellent with no adverse sequelae during a median of 2.9 years of follow-up. Cardiac Tn elevation is common in the pediatric population presenting with SVT. Episode severity, characterized by respiratory or gastrointestinal symptoms, lower mean blood pressure, and increased tachycardia rate and duration are predictive. Clinical follow-up is favorable.

  8. Statewide and national impact of California's Staffing Law on pediatric cardiac surgery outcomes.

    PubMed

    Hickey, Patricia A; Gauvreau, Kimberlee; Jenkins, Kathy; Fawcett, Jacqueline; Hayman, Laura

    2011-05-01

    The objective of the study was to examine the impact of staffing ratios on risk-adjusted outcomes for pediatric cardiac surgery programs in California and relative to other states combined. California performs 20% of the nation's pediatric cardiac surgery and is the only state with a nurse ratio law. Understanding the imposition of mandated ratios on pediatric outcomes is necessary to inform the debate about nurse staffing. Patient variables were extracted from the Healthcare Cost and Utilization Project Kids' Inpatient Database. The American Hospital Association database was used for institutional variables. Descriptive analyses were used to identify and describe patient, nursing, and hospital characteristics. Changes in nursing ratios and full-time equivalents (FTEs) between 2003 and 2006 were examined. Associations between nursing characteristics and each outcome variable were examined using general estimating equation models. The RACHS-1 (Risk Adjustment for Congenital Heart Surgery) risk adjustment method was used for mortality. Hospitals in California significantly increased RN FTEs (P = .025) and RN ratios (P = .036) after enactment of AB 394 in 2006. Neither RN FTEs nor RN ratios were associated with mortality, complications, or resource utilization after risk adjustment. After the law, California's standardized mortality ratio (SMR) decreased more (33%) than in all other states combined (29%). Standardized complication ratio (SCR) increased by 5% but decreased by 5% for all other states combined, and the increase in charge differential ($53,443) was more than twice the increase ($23,119) for other states combined. Hospitals in California made upward adjustments in nursing FTEs and ratios after enactment of AB 394. There was a substantial increase in California's charge differential, a decrease in SMR, and an increase in SCR after enactment of the legislation.

  9. Ultrasound-guided continuous quadratus lumborum block for postoperative analgesia in a pediatric patient.

    PubMed

    Chakraborty, Arunangshu; Goswami, Jyotsna; Patro, Viplab

    2015-02-01

    Quadratus lumborum block is a recently introduced variation of transversus abdominis plane block. In this report, we describe the use of ultrasound-guided continuous quadratus lumborum block for postoperative analgesia in a 7-year-old child scheduled to undergo radical nephrectomy (left-sided) for Wilms tumor. The result was excellent postoperative analgesia and minimal requirement for rescue analgesics. The modification described may allow easier placement of a catheter for continuous infusion of local anesthetic.

  10. Validation of an Ultrasound Cardiac Output Monitor as a Bedside Tool for Pediatric Patients.

    PubMed

    Beltramo, Fernando; Menteer, Jondavid; Razavi, Asma; Khemani, Robinder G; Szmuszkovicz, Jacqueline; Newth, Christopher J L; Ross, Patrick A

    2016-01-01

    The aim of our study was to determine the validity of cardiac output (CO) measurements taken with the ultrasonic cardiac output monitor (USCOM) by comparing to CO measured by pulmonary arterial catheter (PAC) thermodilution during cardiac catheterization. We enrolled thirty-one children (<18 years) undergoing cardiac catheterization in this double-blinded, prospective, observational study. The median CO measured by USCOM was 4.37 L/min (IQR 3.73, 5.60 L/min) compared to 4.28 L/min (IQR 3.52, 5.26 L/min) by PAC thermodilution. The bias (mean difference) between the two methods was 0.2 L/min, and the 95% limits of agreement were -1.2 to 1.6 L/min. The mean percentage error of CO between USCOM and PAC thermodilution was 11%. When excluding a sole outlier, the bias between the two measures decreased to 0.1 L/min (95% limits of agreement -0.6 to 0.9 L/min), and the percentage error was reduced to 8%. The median SVRI measured by USCOM was 22.0 Wood Units (IQR 17.0, 26.8 Wood Units) compared to 22.1 Wood Units (IQR 17.6, 27.4 Wood Units) by PAC thermodilution. Bias (mean difference) between the two methods was -0.6 Wood Units, and the 95% limits of agreement were -8.2 to 6.9 Wood Units. We found that the estimation of CO and by extension SVRI with USCOM is reliable against pulmonary artery catheter thermodilution in children with normal cardiac anatomy. Given the noninvasive nature of USCOM, speed of measurement, and relative ease of use, it may be useful as a bedside tool for pediatric patients.

  11. Cardiac Catheterization in Pediatric Patients Supported by Extracorporeal Membrane Oxygenation: A 15-Year Experience.

    PubMed

    Boscamp, Nicholas S; Turner, Mariel E; Crystal, Matthew; Anderson, Brett; Vincent, Julie A; Torres, Alejandro J

    2017-02-01

    Cardiac catheterization is commonly performed in patients being supported by extracorporeal membrane oxygenation (ECMO). We aimed to evaluate the safety, benefit, and outcomes of catheterization in pediatric patients supported by ECMO. Retrospective review of cardiac catheterizations performed in patients ≤18 years of age while on ECMO at a large tertiary care center between January 2000 and May 2015. A total of 55 catheterizations were performed on 51 patients during 53 unique ECMO courses. Indications for ECMO include ventricular dysfunction (22), cardiac arrest (20), inability to wean from cardiopulmonary bypass (7), and persistent cyanosis (4). Catheterizations included purely diagnostic studies (11), atrial septostomies (34), stenting of vessels or surgical shunts (6), adjustment of a stent (1), coil embolization (1), and endomyocardial biopsy (1). Septostomy was elective in 58.8% of cases (20) and emergent in 41.2% (14). Forty-six catheterizations had either surgical or catheter intervention during the same or subsequent study (83.6%). High severity complications occurred in three patients (5.6%), including one death due to hemothorax after pulmonary artery stent placement. There were no complications during patient transport. In total, 38 out of 53 (71.7%) ECMO courses resulted in decannulation, 29 (54.7%) patients survived to discharge from the hospital, and 25 (47.2%) were alive at follow-up. Cardiac catheterization can be safely performed on patients supported by ECMO. Cardiac catheterization is a critical tool in the early recognition, diagnosis, and direct treatment of hemodynamic/anatomic abnormalities in patients supported by ECMO.

  12. Effectiveness of brain natriuretic peptide in predicting postoperative atrial fibrillation in patients undergoing non-cardiac thoracic surgery.

    PubMed

    Toufektzian, Levon; Zisis, Charalambos; Balaka, Christina; Roussakis, Antonios

    2015-05-01

    A best evidence topic was written according to a structured protocol. The question addressed was whether plasma brain natriuretic peptide (BNP) levels could effectively predict the occurrence of postoperative atrial fibrillation (AF) in patients undergoing non-cardiac thoracic surgery. A total of 14 papers were identified using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. All studies were prospective observational, and all reported a significant association between BNP and N-terminal (NT)-proBNP plasma levels measured in the immediate preoperative period and the incidence of postoperative AF in patients undergoing either anatomical lung resections or oesophagectomy. One study reported a cut-off value of 30 pg/ml above which significantly more patients suffered from postoperative AF (P < 0.0001), while another one reported that this value could predict postoperative AF with a sensitivity of 77% and a specificity of 93%. Another study reported that patients with NT-proBNP levels of 113 pg/ml or above had an 8-fold increased risk of developing postoperative AF. These findings support that BNP or NT-proBNP levels, especially when determined during the preoperative period, if increased, are able to identify patients at risk for the development of postoperative AF after anatomical major lung resection or oesophagectomy. The same does not seem to be true for lesser lung resections. These high-risk patients might have a particular benefit from the administration of prophylactic antiarrhythmic therapy. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

  13. Using Time Series Analysis to Predict Cardiac Arrest in a Pediatric Intensive Care Unit

    PubMed Central

    Kennedy, Curtis E; Aoki, Noriaki; Mariscalco, Michele; Turley, James P

    2015-01-01

    Objectives To build and test cardiac arrest prediction models in a pediatric intensive care unit, using time series analysis as input, and to measure changes in prediction accuracy attributable to different classes of time series data. Methods A retrospective cohort study of pediatric intensive care patients over a 30 month study period. All subjects identified by code documentation sheets with matches in hospital physiologic and laboratory data repositories and who underwent chest compressions for two minutes were included as arrest cases. Controls were randomly selected from patients that did not experience arrest and who survived to discharge. Modeling data was based on twelve hours of data preceding the arrest (reference time for controls). Measurements and Main Results 103 cases of cardiac arrest and 109 control cases were used to prepare a baseline data set that consisted of 1025 variables in four data classes: multivariate, raw time series, clinical calculations, and time series trend analysis. We trained 20 arrest prediction models using a matrix of five feature sets (combinations of data classes) with four modeling algorithms: linear regression, decision tree, neural network and support vector machine. The reference model (multivariate data with regression algorithm) had an accuracy of 78% and 87% area under the receiver operating characteristic curve (AUROC). The best model (multivariate + trend analysis data with support vector machine algorithm) had an accuracy of 94% and 98% AUROC. Conclusions Cardiac arrest predictions based on a traditional model built with multivariate data and a regression algorithm misclassified cases 3.7 times more frequently than predictions that included time series trend analysis and built with a support vector machine algorithm. Although the final model lacks the specificity necessary for clinical application, we have demonstrated how information from time series data can be used to increase the accuracy of clinical

  14. Identifying postoperative atrial fibrillation in cardiac surgical patients posthospital discharge, using iPhone ECG: a study protocol.

    PubMed

    Lowres, Nicole; Freedman, S Ben; Gallagher, Robyn; Kirkness, Ann; Marshman, David; Orchard, Jessica; Neubeck, Lis

    2015-01-13

    Postoperative atrial fibrillation (AF) occurs in 30-40% of patients after cardiac surgery. Identification of recurrent postoperative AF is required to initiate evidence-based management to reduce the risk of subsequent stroke. However, as AF is often asymptomatic, recurrences may not be detected after discharge. This study determines feasibility and impact of a self-surveillance programme to identify recurrence of postoperative AF in the month of posthospital discharge. This is a feasibility study, using a cross-sectional study design, of self-screening for AF using a hand-held single-lead iPhone electrocardiograph device (iECG). Participants will be recruited from the cardiothoracic surgery wards of the Royal North Shore Hospital and North Shore Private Hospital, Sydney, Australia. Cardiac surgery patients admitted in sinus rhythm and experiencing a transient episode of postoperative AF will be eligible for recruitment. Participants will be taught to take daily ECG recordings for 1 month posthospital discharge using the iECG and will be provided education regarding AF, including symptoms and health risks. The primary outcome is the feasibility of patient self-monitoring for AF recurrence using an iECG. Secondary outcomes include proportion of patients identified with recurrent AF; estimation of stroke risk and patient knowledge. Process outcomes and qualitative data related to acceptability of patient's use of the iECG and sustainability of the screening programme beyond the trial setting will also be collected. Primary ethics approval was received on 25 February 2014 from Northern Sydney Local Health District Human Resource Ethics Committee, and on 17 July 2014 from North Shore Private Hospital Ethics Committee. Results will be disseminated via forums including, but not limited to, peer-reviewed publications and presentation at national and international conferences. ACTRN12614000383662. Published by the BMJ Publishing Group Limited. For permission to use

  15. Identifying postoperative atrial fibrillation in cardiac surgical patients posthospital discharge, using iPhone ECG: a study protocol

    PubMed Central

    Lowres, Nicole; Freedman, S Ben; Gallagher, Robyn; Kirkness, Ann; Marshman, David; Orchard, Jessica; Neubeck, Lis

    2015-01-01

    Introduction Postoperative atrial fibrillation (AF) occurs in 30–40% of patients after cardiac surgery. Identification of recurrent postoperative AF is required to initiate evidence-based management to reduce the risk of subsequent stroke. However, as AF is often asymptomatic, recurrences may not be detected after discharge. This study determines feasibility and impact of a self-surveillance programme to identify recurrence of postoperative AF in the month of posthospital discharge. Methods and analysis This is a feasibility study, using a cross-sectional study design, of self-screening for AF using a hand-held single-lead iPhone electrocardiograph device (iECG). Participants will be recruited from the cardiothoracic surgery wards of the Royal North Shore Hospital and North Shore Private Hospital, Sydney, Australia. Cardiac surgery patients admitted in sinus rhythm and experiencing a transient episode of postoperative AF will be eligible for recruitment. Participants will be taught to take daily ECG recordings for 1 month posthospital discharge using the iECG and will be provided education regarding AF, including symptoms and health risks. The primary outcome is the feasibility of patient self-monitoring for AF recurrence using an iECG. Secondary outcomes include proportion of patients identified with recurrent AF; estimation of stroke risk and patient knowledge. Process outcomes and qualitative data related to acceptability of patient's use of the iECG and sustainability of the screening programme beyond the trial setting will also be collected. Ethics and dissemination Primary ethics approval was received on 25 February 2014 from Northern Sydney Local Health District Human Resource Ethics Committee, and on 17 July 2014 from North Shore Private Hospital Ethics Committee. Results will be disseminated via forums including, but not limited to, peer-reviewed publications and presentation at national and international conferences. Trial registration number ACTRN

  16. Pediatric Out-of-Hospital Cardiac Arrest Characteristics and Their Association With Survival and Neurobehavioral Outcome.

    PubMed

    Meert, Kathleen L; Telford, Russell; Holubkov, Richard; Slomine, Beth S; Christensen, James R; Dean, J Michael; Moler, Frank W

    2016-12-01

    To investigate relationships between cardiac arrest characteristics and survival and neurobehavioral outcome among children recruited to the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial. Secondary analysis of Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial data. Thirty-six PICUs in the United States and Canada. All children (n = 295) had chest compressions for greater than or equal to 2 minutes, were comatose, and required mechanical ventilation after return of circulation. Neurobehavioral function was assessed using the Vineland Adaptive Behavior Scales, Second Edition at baseline (reflecting prearrest status) and 12 months postarrest. U.S. norms for Vineland Adaptive Behavior Scales, Second Edition scores are 100 (mean) ± 15 (SD). Higher scores indicate better functioning. Outcomes included 12-month survival and 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70. Cardiac etiology of arrest, initial arrest rhythm of ventricular fibrillation/tachycardia, shorter duration of chest compressions, compressions not required at hospital arrival, fewer epinephrine doses, and witnessed arrest were associated with greater 12-month survival and 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70. Weekend arrest was associated with lower 12-month survival. Body habitus was associated with 12-month survival with Vineland Adaptive Behavior Scales, Second Edition greater than or equal to 70; underweight children had better outcomes, and obese children had worse outcomes. On multivariate analysis, acute life threatening event/sudden unexpected infant death, chest compressions more than 30 minutes, and weekend arrest were associated with lower 12-month survival; witnessed arrest was associated with greater 12-month survival. Acute life threatening event/sudden unexpected infant death, other respiratory causes of arrest

  17. The Relationship between Intra-Operative Transfusions and Nadir Hematocrit on Post-Operative Outcomes after Cardiac Surgery.

    PubMed

    Goldberg, Joshua B; Shann, Kenneth G; Fitzgerald, David; Fuller, John; Paugh, Theron A; Dickinson, Timothy A; Paone, Gaetano; Prager, Richard L; Likosky, Donald S

    2016-12-01

    Uncertainty exists regarding the optimal strategy for the management of anemia in the setting of cardiac surgery. We sought to improve our understanding of the role of intra-operative hematocrit (HCT) and transfusions on peri-operative outcomes following cardiac surgery. A total of 18,886 patients undergoing on-pump cardiac surgery were identified from a multi-institutional registry including surgical and perfusion data. Patients were divided into four groups based on their intra-operative nadir HCT (<21 or ≥21) and whether or not they received intra-operative red blood cell (+RBC or -RBC) transfusions. Outcomes were adjusted for the Society of Thoracic Surgeons predicted risk of mortality (PROM), pre-operative HCT, and medical center. Regardless of nadir HCT cohort, those who received a transfusion had higher PROM relative to patients who did not receive a transfusion. The mean PROM was significantly higher among those HCT ≥21 + RBC (5.3%) vs. HCT ≥ 21 - RBC (1.9%), p < .001. Similarly, the PROM was significantly higher among HCT <21 + RBC (5.1%) vs. those HCT <21 - RBC (3.1%), p < .001. Adjusted outcomes demonstrated an increased impact of RBC transfusions on adverse outcomes irrespective of nadir HCT including stroke (p < .001), renal failure (p < .001), prolonged ventilation (p < .001), and mortality (p < .001). This study demonstrates that transfusions have a more profound effect on post-operative cardiac surgery outcomes than anemia.

  18. Safety advantage of modified minimally invasive cardiac surgery for pediatric patients.

    PubMed

    Nakanishi, Keisuke; Matsushita, Satoshi; Kawasaki, Shiori; Tambara, Keiichi; Yamamoto, Taira; Morita, Terumasa; Inaba, Hirotaka; Kuwaki, Kenji; Amano, Atsushi

    2013-03-01

    Minimally invasive cardiac surgery (MICS) using a small surgical incision in children provides less physical stress. However, concern about safety due to the small surgical field has been noted. Recently, the authors developed a modified MICS procedure to extend the surgical field. This report assesses the safety and benefit of this modified procedure by comparing three procedures: the modified MICS (group A), conventional MICS (group B), and traditional open heart surgery (group C). A retrospective analysis was performed with 111 pediatric patients (age, 0-9 years; weight, 5-30 kg) who underwent cardiac surgery for simple cardiac anomaly during the period 1996-2010 at Juntendo University Hospital. The modified MICS method to extend the surgical view has been performed since 2004. A skin incision within 5 cm was made below the nipple line, and the surgical field was easily moved by pulling up or down using a suture or a hemostat. The results showed no differences in terms of gender, age, weight, or aortic cross-clamp time among the groups. Analysis of variance (ANOVA) indicated significant differences in mean time before cardiopulmonary bypass (CPB), CPB time, operation time, and bleeding. According to the indices, modified MICS was similar to traditional open surgery and shorter time or lower bleeding volume than conventional MICS. No major mortality or morbidity occurred. In conclusion, the modified MICS procedure, which requires no special techniques, was as safe as conventional open heart surgery and even reduced perioperative morbidity.

  19. Safety and postoperative adverse events in pediatric otologic surgery: analysis of American College of Surgeons NSQIP-P 30-Day outcomes.

    PubMed

    Roxbury, Christopher R; Yang, Jingyan; Salazar, Jose; Shah, Rahul K; Boss, Emily F

    2015-05-01

    Describe safety and postoperative sequelae of pediatric otologic surgery and identify predictive factors for postoperative events. Retrospective cohort study of the American College of Surgeons National Surgery Quality Improvement Program-Pediatric (NSQIP-P) database. Data pooled from the 2012 NSQIP-P public use file (50 institutions). Current procedural terminology codes were used to identify children who underwent otologic surgery. Variables of interest included demographics and 30-day postoperative events grouped as reoperation, readmission, and complication. Event rates were determined and prevalence of events compared by procedure type and within patient subgroups according to chi-square analysis. Multivariate logistic regression evaluated predictive factors for postoperative events. Of 37,319 pediatric operations, 2556 (6.8%) were otologic procedures. The most common procedure was tympanoplasty (n = 893, 34.9%), followed by myringoplasty (n = 741, 30.0%), cochlear implantation (n = 464, 18.2%), and tympanomastoidectomy (n = 458, 17.9%). There were 9 reoperations (0.4%), 32 readmissions (1.3%), and 18 complications (0.7%). Children undergoing tympanomastoidectomy or cochlear implantation were more likely to be readmitted irrespective of other factors (odds ratio = 5.5, P = .010; odds ratio = 3.5, P = .083). Children <3 years old were 4 times more likely to be readmitted than older children (odds ratio = 4.4, P < .001). Pediatric otologic procedures are common and have low rates of global 30-day postoperative events. Tympanomastoidectomy and cochlear implantation have the highest risk of 30-day readmission. Young children (<3 years) are more likely to be readmitted following these procedures. Further optimization of the NSQIP-P to include specialty and procedure-specific variables is necessary to assess complete, actionable outcomes of pediatric otologic surgery, however the present study provides a foundation to build upon for safety and quality improvement

  20. Efficacy of surgical transversus abdominis plane block for postoperative pain relief following abdominal surgery in pediatric patients.

    PubMed

    Lapmahapaisan, Saowaphak; Tantemsapya, Niramol; Aroonpruksakul, Naiyana; Maisat, Wiriya; Suraseranivongse, Suwannee

    2015-06-01

    Transversus abdominis plane (TAP) block is a promising effective method for postoperative pain control after major abdominal surgery. Using a landmark technique, it is easily performed, but its popularity has decreased because of less efficacy due to inaccurate injection and the potential for intraperitoneal organ damage. Ultrasound-guided TAP block provides better results and less complications, but it requires experienced operators. Surgically administered TAP (sTAP) block is a simple technique and may cause less complications. This study was aimed to determine the efficacy of sTAP on postoperative pain control in pediatric patients following a major abdominal surgery, compared with local anesthetic infiltration and no block. This stratified, randomized controlled trial was conducted in pediatric patients, below the age of 15 years, who underwent non-laparoscopic major abdominal surgery. Patients were allocated into three groups. The control group received no block; the LA group received 0.25% bupivacaine for local wound infiltration; and the sTAP group received 0.25% bupivacaine for TAP block performed by a surgeon before abdominal wall closure. Parameter records included the incidence of inadequate pain control, time to first analgesic, opioid requirement within 24 h, and complications of these techniques. Fifty-four patients were recruited. There was no significant difference in the incidence of inadequate pain control (P = 0.589). The median time to first analgesic was 380 min in the sTAP group compared with 370 and 420 min in the LA and control groups, respectively (95%CI = 193-567, 121-619, and 0-1012; P = 0.632). The median dose of total opioid requirement (calculated as fentanyl-equivalent dose) was 1.95, 2.05, and 2.04 μg·kg(-1) ·24 h(-1) in the sTAP, LA, and control groups, respectively (IQR = 0.65, 2.20; 0.59, 3.32; 0.38, 2.60; P = 0.723). No complications of sTAP block were detected. There was no significant advantage of the s

  1. Hyponatremia in the postoperative craniofacial pediatric patient population: a connection to cerebral salt wasting syndrome and management of the disorder.

    PubMed

    Levine, J P; Stelnicki, E; Weiner, H L; Bradley, J P; McCarthy, J G

    2001-11-01

    Hyponatremia after cranial vault remodeling has been noted in a pediatric patient population. If left untreated, the patients may develop a clinical hypoosmotic condition that can lead to cerebral edema, increased intracranial pressure, and eventually, to central nervous system and circulatory compromise. The hyponatremia has traditionally been attributed to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH); however, in our patients the treatment has been resuscitation with normal saline as opposed to fluid restriction (the accepted treatment of SIADH), thus placing the diagnosis of SIADH in question. Patients who developed hyponatremia after intracranial injury or surgery were, until recently, grouped together as having SIADH. However, there are diagnosis and treatment differences between SIADH and another distinct but poorly understood disorder that is designated cerebral salt wasting syndrome (CSW). CSW is associated with increased urine output and increased urine sodium concentration and volume contraction, and it is frequently seen after a central nervous system trauma. We therefore developed a prospective study to evaluate the cause of the sodium imbalance.Ten consecutive pediatric patients who underwent intracranial surgery for various craniosynostotic disorders were postoperatively monitored in the pediatric intensive care unit for hemodynamic, respiratory, and fluid management. The first four patients were evaluated for electrolyte changes and overall fluid balance to determine the consistency with which these changes occurred. The remaining six patients had daily (including preoperative) measurement of serum electrolytes, urine electrolytes, urine osmolarity, serum antidiuretic hormone (ADH), aldosterone, and atrial natriuretic hormone (ANH). All patients received normal saline intravenous replacement fluid in the postoperative period. All of the patients developed a transient hyponatremia postoperatively, despite normal saline

  2. Comparison of Dexmedetomidine and Fentanyl as an Adjuvant to Ropivacaine for Postoperative Epidural Analgesia in Pediatric Orthopedic Surgery.

    PubMed

    Park, Sang Jun; Shin, Seokyung; Kim, Shin Hyung; Kim, Hyun Woo; Kim, Seung Hyun; Do, Hae Yoon; Choi, Yong Seon

    2017-05-01

    Opioids are commonly used as an epidural adjuvant to local anesthetics, but are associated with potentially serious side effects, such as respiratory depression. The aim of this study was to compare the efficacy and safety of dexmedetomidine with that of fentanyl as an adjuvant to epidural ropivacaine in pediatric orthopedic surgery. This study enrolled 60 children (3-12 years old) scheduled for orthopedic surgery of the lower extremities and lumbar epidural patient-controlled analgesia (PCA). Children received either dexmedetomidine (1 μg/kg) or fentanyl (1 μg/kg) along with 0.2% ropivacaine (0.2 mL/kg) via an epidural catheter at 30 minutes before the end of surgery. Postoperatively, the children were observed for ropivacaine consumption via epidural PCA, postoperative pain intensity, need for rescue analgesics, emergence agitation, and other adverse effects. The mean dose of bolus epidural ropivacaine was significantly lower within the first 6 h after surgery in the dexmedetomidine group, compared with the fentanyl group (0.029±0.030 mg/kg/h vs. 0.053±0.039 mg/kg/h, p=0.012). The median pain score at postoperative 6 h was also lower in the dexmedetomidine group, compared to the fentanyl group [0 (0-1.0) vs. 1.0 (0-3.0), p=0.039]. However, there was no difference in the need for rescue analgesia throughout the study period between groups. The use of dexmedetomidine as an epidural adjuvant had a significantly greater analgesic and local anesthetic-sparing effect, compared to fentanyl, in the early postoperative period in children undergoing major orthopedic lower extremity surgery.

  3. Comparison of Dexmedetomidine and Fentanyl as an Adjuvant to Ropivacaine for Postoperative Epidural Analgesia in Pediatric Orthopedic Surgery

    PubMed Central

    Park, Sang Jun; Shin, Seokyung; Kim, Shin Hyung; Kim, Hyun Woo; Kim, Seung Hyun; Do, Hae Yoon

    2017-01-01

    Purpose Opioids are commonly used as an epidural adjuvant to local anesthetics, but are associated with potentially serious side effects, such as respiratory depression. The aim of this study was to compare the efficacy and safety of dexmedetomidine with that of fentanyl as an adjuvant to epidural ropivacaine in pediatric orthopedic surgery. Materials and Methods This study enrolled 60 children (3–12 years old) scheduled for orthopedic surgery of the lower extremities and lumbar epidural patient-controlled analgesia (PCA). Children received either dexmedetomidine (1 µg/kg) or fentanyl (1 µg/kg) along with 0.2% ropivacaine (0.2 mL/kg) via an epidural catheter at 30 minutes before the end of surgery. Postoperatively, the children were observed for ropivacaine consumption via epidural PCA, postoperative pain intensity, need for rescue analgesics, emergence agitation, and other adverse effects. Results The mean dose of bolus epidural ropivacaine was significantly lower within the first 6 h after surgery in the dexmedetomidine group, compared with the fentanyl group (0.029±0.030 mg/kg/h vs. 0.053±0.039 mg/kg/h, p=0.012). The median pain score at postoperative 6 h was also lower in the dexmedetomidine group, compared to the fentanyl group [0 (0–1.0) vs. 1.0 (0–3.0), p=0.039]. However, there was no difference in the need for rescue analgesia throughout the study period between groups. Conclusion The use of dexmedetomidine as an epidural adjuvant had a significantly greater analgesic and local anesthetic-sparing effect, compared to fentanyl, in the early postoperative period in children undergoing major orthopedic lower extremity surgery. PMID:28332374

  4. [Effect of early postoperative use of ACEI/ARB or diuretics on the incidence of acute kidney injury after cardiac surgery in elderly patients].

    PubMed

    Hu, Peng-hua; Chen, Yuan-han; Liang, Xin-ling; Li, Rui-zhao; Li, Zhi-lian; Jiang, Fen; Shi, Wei

    2013-07-01

    To explore the influence of early postoperative use of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) or diuretics on acute kidney injury (AKI) after cardiac surgery in elderly patients. Data from elderly patients (age≥60 years old) who underwent cardiac surgery with extracorporeal circulation in Guangdong General Hospital between January 2007 and December 2010 were analyzed in this retrospective research. The primary endpoint was AKI as diagnosed according to the serum creatinine criteria of RIFLE (risk, injury, failure, loss, end stage renal disease). The baseline serum creatinine was defined as the latest serum creatinine level before cardiac surgery. Multivariate analysis by logistic regression was used to obtain the independent risk factors for AKI. Among 618 elderly patients, 76 (12.3%) patients received ACEI/ARB during early postoperative period, 491 (79.4%) patients were given diuretics during early postoperative period, and postoperative AKI occurred in 394 (63.8%) patients. The incidence of AKI was 46.1% in patients who received early postoperative ACEI/ARB, and 66.2% in patients who did not (P<0.001). Patients who received diuretics postoperatively were less likely to suffer from AKI compared with patients who did not (57.0% vs. 89.8%, P<0.001). After adjustment of other potential factors of postoperative AKI, logistic regression analysis showed that early postoperative use of ACEI/ARB [odds ratio (OR)=0.131, 95% confidence interval (95%CI) 0.033-0.517, P=0.004], and early postoperative use of diuretics (OR=0.149, 95%CI 0.076-0.291, P<0.001) independently predicted the occurrence of AKI. Early postoperative use of ACEI/ARB or diuretics is associated with a lower incidence of AKI after cardiac surgery with extracorporeal circulation in elderly patients.

  5. The Role of Regional Oxygen Saturation Using Near-Infrared Spectroscopy and Blood Lactate Levels as Early Predictors of Outcome After Pediatric Cardiac Surgery.

    PubMed

    Vida, Vladimiro L; Tessari, Chiara; Cristante, Alessia; Nori, Roberta; Pittarello, Demetrio; Ori, Carlo; Cogo, Paola E; Perissinotto, Egle; Stellin, Giovanni

    2016-08-01

    The purpose of the study was to evaluate the association between regional oxygen saturation (rSO2) desaturation score (calculated by multiplying the rSO2 < 50% by time in seconds the preoperative baseline value) measured with near-infrared spectroscopy and the peak of lactate with postoperative major morbidities in pediatric patients who undergo cardiac surgery. We retrospectively analyzed the postoperative course of 152 patients between January 2012 and December 2013, for whom we continuously monitored cerebral rSO2 using near-infrared spectroscopy and serial arterial blood lactate levels for at least 48 hours. The median age at surgery was 128 days (interquartile range [IQR], 17-537 days). Thirty-nine patients had a single ventricle physiology (26%) and 135 patients (89%) required the use of cardiopulmonary bypass (median time of 130 minutes; IQR, 93-172 minutes). Median postoperative peak lactate level was 3 mmol/L (IQR, 2-5.3 mmol/L); 52 patients (34%) had a postoperative lactate level > 4.6 mmol/L. The median postoperative rSO2 desaturation score was 157 (IQR, 0-2050); 62 patients (41%) had an rSO2 desaturation score > 345. Fifty-seven patients (37%) had postoperative major morbidities. Using a multivariable regression model only rSO2 desaturation score > 345 was independently associated with major morbidities after surgery (odds ratio, 27.26; 95% confidence interval, 10.18-73.00). The proportion of patients with an rSO2 desaturation score > 345 within 240 minutes after surgery was higher than the rate of those who showed a peak of lactate > 4.6 mmol/L (84% vs 59%; P = 0.05). The postoperative rSO2 desaturation score has a stronger association with major postoperative morbidities than lactate and it also provides an earlier warning sign of hemodynamic or metabolic compromise. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

  6. Preoperative regional cerebral oxygen saturation is a predictor of postoperative delirium in on-pump cardiac surgery patients: a prospective observational trial

    PubMed Central

    2011-01-01

    Introduction Postoperative delirium is an important problem in patients undergoing major surgery. Cerebral oximetry is a non-invasive method to detect imbalances in the cerebral oxygen supply/demand-ratio. Low preoperative cerebral oxygen saturation (ScO2) levels have been associated with postoperative delirium in non-cardiac surgery patients. The present prospective observational study determines the relationship between pre- and intra-operative ScO2 levels and postoperative delirium in patients undergoing on-pump cardiac surgery. Methods After approval of the local ethical committee and written informed consent, N = 231 patients scheduled for elective/urgent cardiac surgery were enrolled. Delirium was assessed by the confusion-assessment-method for the intensive care unit (CAM-ICU) on the first three days after surgery. ScO2 was obtained on the day before surgery, immediately before surgery and throughout the surgical procedure. Preoperative cognitive function, demographic, surgery related, and intra- and post-operative physiological data were registered. Results Patients with delirium had lower pre- and intra-operative ScO2 readings, were older, had lower mini-mental-status-examination(MMSE) scores, higher additive EuroScore and lower preoperative haemoglobin-levels. The binary logistic regression identified older age, lower MMSE, neurological or psychiatric disease and lower preoperative ScO2 as independent predictors of postoperative delirium. Conclusions The presented study shows that a low preoperative ScO2 is associated with postoperative delirium after on-pump cardiac surgery. PMID:21929765

  7. Pediatric cardiac surgery Parent Education Discharge Instruction (PEDI) program: a pilot study.

    PubMed

    Staveski, Sandra L; Zhelva, Bistra; Paul, Reena; Conway, Rosalind; Carlson, Anna; Soma, Gouthami; Kools, Susan; Franck, Linda S

    2015-01-01

    In developing countries, more children with complex cardiac defects now receive treatment for their condition. For successful long-term outcomes, children also need skilled care at home after discharge. The Parent Education Discharge Instruction (PEDI) program was developed to educate nurses on the importance of discharge teaching and to provide them with a structured process for conducting parent teaching for home care of children after cardiac surgery. The aim of this pilot study was to generate preliminary data on the feasibility and acceptability of the nurse-led structured discharge program on an Indian pediatric cardiac surgery unit. A pre-/post-design was used. Questionnaires were used to evaluate role acceptability, nurse and parent knowledge of discharge content, and utility of training materials with 40 nurses and 20 parents. Retrospective audits of 50 patient medical records (25 pre and 25 post) were performed to evaluate discharge teaching documentation. Nurses' discharge knowledge increased from a mean of 81% to 96% (P = .001) after participation in the training. Nurses and parents reported high levels of satisfaction with the education materials (3.75-4 on a 4.00-point scale). Evidence of discharge teaching documentation in patient medical records improved from 48% (12 of 25 medical records) to 96% (24 of 25 medical records) six months after the implementation of the PEDI program. The structured nurse-led parent discharge teaching program demonstrated feasibility, acceptability, utility, and sustainability in the cardiac unit. Future studies are needed to examine nurse, parent, child, and organizational outcomes related to this expanded nursing role in resource-constrained environments. © The Author(s) 2014.

  8. Testing the pediatric cardiac quality of life inventory in the United kingdom.

    PubMed

    Wray, Jo; Franklin, Rodney; Brown, Kate; Cassedy, Amy; Marino, Bradley S

    2013-02-01

    To establish the validity and reliability of the Pediatric Cardiac Quality of Life Inventory (PCQLI) for children with heart disease in the United Kingdom. Three paediatric cardiac centres recruited patients aged 8-18 years with heart disease. Patient-parent pairs completed a disease-specific paediatric cardiac quality of life measure (PCQLI), a generic quality of life measure (PedsQL4.0) and behaviour and self-perception questionnaires. Validity was assessed by correlation of PCQLI scores with heart disease severity, medical care utilization, and PedsQL, behaviour and self-perception scores, and by correlation of patient and parent PCQLI scores. Reliability was evaluated by administering the PCQLI at two time points. The study was completed by 771 patient-parent pairs. Validity was confirmed by the association of lower total PCQLI scores with more complex heart disease and a greater number of hospitalizations and cardiac surgeries (all p < 0.001); moderate to good correlations between patient and parent scores (0.50-0.68); and fair to good correlations between scores for the PCQLI and PedsQL4.0 (0.67-0.77), self-perception (0.42-0.49) and behaviour measures (0.18-0.62). Test-retest reliability correlations were high (0.72-0.90). The PCQLI is a reliable and valid disease-specific quality-of-life measure for children with heart disease in the United Kingdom. ©2012 The Author(s)/Acta Paediatrica ©2012 Foundation Acta Paediatrica.

  9. Comparison of the Perioperative and Postoperative Effects of Levobupivacaine and of Levobupivacaine + Adrenaline in Pediatric Tonsillectomy: A Double-Blind Randomized Study

    PubMed Central

    Sizer, Cigdem; Atici, Sait Selcuk; Arican, Sule; Karaibrahimoglu, Adnan; Kara, Inci

    2017-01-01

    Objectives We aimed to assess the effects of levobupivacaine and of levobupivacaine + adrenaline administered during pediatric tonsillectomy on the postoperative period. Methods A total of 90 patients between the ages of five and twelve were divided randomly into two groups before tonsillectomy: levobupivacaine only (0.5%) 0.4 mg·kg−1 or levobupivacaine (0.5%) 0.4 mg·kg−1 + adrenaline (1 : 200.000) administered by means of peritonsillar infiltration. Primary outcomes were postoperative pain scores recorded at various intervals until 24 hours postoperatively. Secondary outcomes included postoperative nausea and vomiting (PONV), time to first oral intake, time to the first administration of analgesics and total consumption of analgesics, and the amount of bleeding for all children. Results In both groups, patients had the same postoperative pain scores and PONV rates, and equal amounts of analgesics were consumed up to 24 hours postoperatively. The two groups also had the same time until first oral intake, recovery time and time to the first analgesic request, and amount of bleeding. Conclusions Perioperative levobupivacaine infiltration on its own is a valid alternative to the combination of levobupivacaine + adrenaline for perioperative and postoperative effectiveness in pediatric tonsillectomy. This trial is registered with Australian New Zealand Clinical Trial Registry ACTRN: ACTRN12617001167358. PMID:28912639

  10. Comparison of caudal tramadol versus caudal fentanyl with bupivacaine for prolongation of postoperative analgesia in pediatric patients

    PubMed Central

    Solanki, NM; Engineer, SR; Jansari, DB; Patel, RJ

    2016-01-01

    Background and Aims: Caudal block is a common technique for pediatric analgesia for infraumblical surgeries. Because of the short duration of analgesia with bupivacaine alone various additive have been used to prolong the action of bupivacaine. The present study was aimed to evaluate the analgesic effect of tramadol or fentanyl added to bupivacaine for infraumblical surgeries in pediatric patients. Materials and Methods: We conducted a prospective, randomized, single-blind controlled trial. After written informed consent from parents, 100 patients belonging to American Society of Anesthesiologist physical status I-II, in the age group of 1-12 years, of either sex undergoing infraumblical surgery under general anesthesia were divided into two groups. Group BT received 1 ml/kg of 0.25% bupivacaine with tramadol 2 mg/kg in normal saline and Group BF received 1 ml/kg of 0.25% bupivacaine with fentanyl 2 μg/kg in normal saline with maximum volume of 12 ml in both groups. All patients were assessed intraoperatively for hemodynamic changes, the requirement of sevoflurane concentration, as well as postoperatively for pain by using FLACC (F = Face, L = Leg, A = Activity, C = Cry, C = Consolability), pain score and for sedation by using four point sedation score. Results: The mean duration of analgesia was 10–18 h in Group BT while in Group BF it was 7-11 h. The postoperatively period up to 1½ h, Group BF had higher sedation score up to two as compared to that below one on Group BT. Conclusion: Caudal tramadol significantly prolongs the duration of analgesia as compared to caudal fentanyl without any side effects. PMID:27051365

  11. [Analysis of patients control analgesia with trimeperidine and ketoprofen for postoperative pain management in patients who underwent cardiac surgery].

    PubMed

    2011-01-01

    The aim of the study is to discover adequate method of early postoperative period pain management in patients after cardiac surgery. In prospective randomized competitive study were analyzed three algorithms of analgesia: first patients controlled analgesia (PCA) with trimeperidine and (NSAID) ketoprofen, second PCA with only trimeperidine and third is ketoprofen combined with intramuscular injection of trimeperidine. There were 75 pations studied at the age of 40 to 65. The pain level was assessed according to verbal 5 points scale, inspiration lung capacity which was measured by incentive spirometry. It was shown that NSAID were safe to use in early postoperative period in patients after cardiac surgery. Combination of ketoprofen and trimeperiden showed best results in pain management. Consumption dose of trimeperidine was smaller in first group but larger than in third group where this drug was introduced fractional. All side effects were associated with trimeperedine and were depended on a dose. Patients of second group had nausea, vomiting, dizziness, weakness, enteroparesis considerably often comparing to patients of other groups, moreover rate of enteroparesis was minimal in the third group.

  12. Postoperative Neurocognitive Dysfunction in Patients Undergoing Cardiac Surgery after Remote Ischemic Preconditioning: A Double-Blind Randomized Controlled Pilot Study

    PubMed Central

    Meybohm, Patrick; Renner, Jochen; Broch, Ole; Caliebe, Dorothee; Albrecht, Martin; Cremer, Jochen; Haake, Nils; Scholz, Jens; Zacharowski, Kai; Bein, Berthold

    2013-01-01

    Background Remote ischemic preconditioning (RIPC) has been shown to enhance the tolerance of remote organs to cope with a subsequent ischemic event. We hypothesized that RIPC reduces postoperative neurocognitive dysfunction (POCD) in patients undergoing complex cardiac surgery. Methods We conducted a prospective, randomized, double-blind, controlled trial including 180 adult patients undergoing elective cardiac surgery with cardiopulmonary bypass. Patients were randomized either to RIPC or to control group. Primary endpoint was postoperative neurocognitive dysfunction 5–7 days after surgery assessed by a comprehensive test battery. Cognitive change was assumed if the preoperative to postoperative difference in 2 or more tasks assessing different cognitive domains exceeded more than one SD (1 SD criterion) or if the combined Z score was 1.96 or greater (Z score criterion). Results According to 1 SD criterion, 52% of control and 46% of RIPC patients had cognitive deterioration 5–7 days after surgery (p = 0.753). The summarized Z score showed a trend to more cognitive decline in the control group (2.16±5.30) compared to the RIPC group (1.14±4.02; p = 0.228). Three months after surgery, incidence and severity of neurocognitive dysfunction did not differ between control and RIPC. RIPC tended to decrease postoperative troponin T release at both 12 hours [0.60 (0.19–1.94) µg/L vs. 0.48 (0.07–1.84) µg/L] and 24 hours after surgery [0.36 (0.14–1.89) µg/L vs. 0.26 (0.07–0.90) µg/L]. Conclusions We failed to demonstrate efficacy of a RIPC protocol with respect to incidence and severity of POCD and secondary outcome variables in patients undergoing a wide range of cardiac surgery. Therefore, definitive large-scale multicenter trials are needed. Trial Registration ClinicalTrials.gov NCT00877305 PMID:23741380

  13. [Hyperlactatemia in surgical ablation of atrial fibrillation and cardiac surgery. Is it a predictive factor of postoperative morbidity?].

    PubMed

    Carmona, P; Mateo, E; Hornero, F; Errando, C L; Vázquez, A; Llagunes, J; De Andrés, J

    2014-01-01

    Increased serum lactate in postoperative cardiac surgery is very common and its pathogenesis is due to multiple factors. The elevation of serum lactate is associated with tissue hypoxia (hyperlactatemia type A) and non-hypoxic (hyperlactatemia type B) metabolic disorders. The aim of the study was to assess the evolution of postoperative lactate in surgical atrial fibrillation ablation during cardiac surgery, and to determine whether lactate levels could be predictors of morbimortality. A case-control study was conducted on 32 patients undergoing surgical atrial fibrillation ablation and cardiac surgery (Maze group) and 32 matched patients (Control group), operated on between 2011 and 2012. An analysis was made of the levels of postoperative lactate, perioperative morbimortality and hospital length of stay. A univariate and multivariate study was performed for a composite endpoint of morbimortality, and prolonged length of stay. Lactate levels were significantly higher at 6, 12 and 24h in the Maze group. The univariate analysis showed that being in the Maze group (OR 3.88; 95% CI 1.3-11.1; P=.01) and an elevated lactate at 12h (OR 1.33; 95% CI 1.01-1.7; P=.04) were significant predictors of major complications, mortality, and longer hospital stays. In the multivariate analysis, surgical atrial fibrillation ablation (Maze group) was an independent predictor of major complications (OR 4.13; 95% CI 1.312.9; P=.015) for the morbimortality composite endpoint (OR 3.9; 95% CI 1.3-11.6; P=.01), and prolonged length of stay in the Intensive Care Unit (OR 5.7; 95% CI 2.01-15.7; P=.01). The atrial fibrillation surgical ablation may be a not-yet-described cause of type B hyperlactatemia, with serum peak values being reached between 4-24h after cardiac surgery. The predictive value of this elevation, its correlation with morbimortality, its sensitivity and specificity to discriminate the significant thresholds needs to be defined. Copyright © 2013 Sociedad Española de

  14. Radiation exposure to the pediatric patient during cardiac catheterization and angiocardiography. Emphasis on the thyroid gland

    SciTech Connect

    Martin, E.C.; Olson, A.P.; Steeg, C.N.; Casarella, W.J.

    1981-07-01

    Thermoluminescent dosimetry was used to measure the radiation exposure to the skin, thyroid and gonads in 50 consecutive pediatric patients undergoing cardiac catheterization and angiocariography using cine photofluorography. Average exposures were 17.1 R to the skin, 2.3 R to the thyroid and 0.1 R to the gonads. Fluoroscopy accounted for approximately 80% of the skin and thyroid exposure and cine photofluorography for 20 to 25%. Occasional primary-beam irradiation was the major contributor to gonad exposure. Internal scatter of the incident x-ray beam was primarily responsible for thyroid exposure, so that infants received relatively high exposures; one receiving 7.3 R. The thyroid was not frequently in the primary beam. The significance of high radiation exposure to the thyroid, and in particular its relationship to thyroid carcinoma, are discussed. The results are compared with other series in the literature and relative exposures of cine photofluorography and serial filming are contrasted.

  15. Radiation exposure to the pediatric patient during cardiac catheterization and angiocardiography. Emphasis on the thyroid gland

    SciTech Connect

    Martin, E.C.; Olson, A.P.; Steeg, C.N.; Casarella, W.J.

    1981-07-01

    Thermoluminescent dosimetry was used to measure the radiation exposure to the skin, thyroid and gonads in 50 consecutive pediatric patients undergoing cardiac catheterization and angiocardiography using cine photofluorography. Average exposures were 17.1 R to the skin, 2.3 R to the thyroid and 0.1 R to the gonads. Fluoroscopy accounted for approximately 80% of the skin and thyroid exposure and cine photofluorography for 20-25%. Occasional primary-beam irradiation was the major contributor to gonad exposure. Internal scatter of the incident x-ray beam was primarily responsible for thyroid exposure, so that infants received relatively high exposures; one receiving 7.3 R. The thyroid was not frequently in the primary beam. The significance of high radiation exposure to the thyroid, and in particular its relationship to thyroid carcinoma, are discussed. The results are compared with other series in the literature and relative exposures of cine photofluorography and serial filming are contrasted.

  16. Cardiac arrest and resuscitation in the pediatric intensive care unit: a prospective multicenter multinational study.

    PubMed

    Del Castillo, Jimena; López-Herce, Jesús; Cañadas, Sonia; Matamoros, Martha; Rodríguez-Núnez, Antonio; Rodríguez-Calvo, Ana; Carrillo, Angel

    2014-10-01

    The aim of the study was to analyze the mortality and neurological outcome factors of in-pediatric intensive care unit (in-PICU) cardiac arrest (CA) in a multicenter international study. It was a prospective observational multicenter study in Latin-American countries, Spain, Portugal, and Italy. A total of 250 children aged from 1 month to 18 years who suffered in-PICU CA were studied. Countries and patient-related variables, arrest life, support-related variables, procedures, and clinical and neurological status at hospital discharge according to the Pediatric Cerebral Performance Category (PCPC) scale were registered. The primary endpoint was survival at hospital discharge and neurological outcome at the same time was the secondary endpoint. Univariate and multivariate logistic regression analyses were performed. Return of spontaneous circulation maintained longer than 20 min was achieved in 172 patients (69.1%) and 101 (40.4%) survived to hospital discharge. In the univariate analysis, oncohematologic diseases, inotropic infusion at the time of CA, sepsis and neurologic causes of CA, primary cardiac arrest, need of adrenaline, bicarbonate or volume expansion during resuscitation, and long duration of resuscitation were related with mortality. In the multivariate logistic regression analysis, factors related to mortality were hemato-oncologic illness and previous treatment with vasoactive drugs at the time of CA event, neurological etiology of CA, and cardiopulmonary resuscitation (CPR) duration for more than 10 min. One year after CA, neurological status was assessed in 65 patients; among them, 81.5% had mild disabilities or none. Survival with good neurological outcome of CA in the PICU is improving. The most important prognostic indicator is the duration of resuscitation. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  17. Effect of defibrillation energy dose during in-hospital pediatric cardiac arrest.

    PubMed

    Meaney, Peter A; Nadkarni, Vinay M; Atkins, Dianne L; Berg, Marc D; Samson, Ricardo A; Hazinski, Mary Fran; Berg, Robert A

    2011-01-01

    To examine the effectiveness of initial defibrillation attempts. We hypothesized that (1) an initial shock dose of 2 ± 10 J/kg would be less effective for terminating fibrillation than suggested in published historical data and (2) a 4 J/kg shock dose would be more effective. This was a National Registry of Cardiopulmonary Resuscitation prospective, multisite, observational study of in-hospital pediatric (aged ≤18 years) ventricular fibrillation or pulseless ventricular tachycardia cardiac arrests from 2000-2008. Termination of ventricular fibrillation or pulseless ventricular tachycardia and event survival after initial shocks of 2 J/kg were compared with historic controls and a 4 J/kg shock dose. Of 266 children with 285 events, 173 of 285 (61%) survived the event and 61 of 266 (23%) survived to discharge. Termination of fibrillation after initial shock was achieved for 152 of 285 (53%) events. Termination of fibrillation with 2 ± 10 J/kg was much less frequent than that seen among historic control subjects (56% vs 91%; P < .001), but not different than 4 J/kg. Compared with 2 J/kg, an initial shock dose of 4 J/kg was associated with lower rates of return of spontaneous circulation (odds ratio: 0.41 [95% confidence interval: 0.21-0.81]) and event survival (odds ratio: 0.42 [95% confidence interval: 0.18-0.98]). The currently recommended 2 J/kg initial shock dose for in-hospital cardiac arrest was substantially less effective than previously published. A higher initial shock dose (4 J/kg) was not associated with superior termination of ventricular fibrillation or pulseless ventricular tachycardia or improved survival rates. The optimal pediatric defibrillation dose remains unknown.

  18. Multicenter Quality Improvement Project to Prevent Sternal Wound Infections in Pediatric Cardiac Surgery Patients.

    PubMed

    Woodward, Cathy; Taylor, Richard; Son, Minnette; Taeed, Roozbeh; Jacobs, Marshall L; Kane, Lauren; Jacobs, Jeffrey P; Husain, S Adil

    2017-07-01

    Children undergoing cardiac surgery are at risk for sternal wound infections (SWIs) leading to increased morbidity and mortality. Single-center quality improvement (QI) initiatives have demonstrated decreased infection rates utilizing a bundled approach. This multicenter project was designed to assess the efficacy of a protocolized approach to decrease SWI. Pediatric cardiac programs joined a collaborative effort to prevent SWI. Programs implemented the protocol, collected compliance data, and provided data points from local clinical registries using Society of Thoracic Surgery Congenital Heart Surgery Database harvest-compliant software or from other registries. Nine programs prospectively collected compliance data on 4,198 children. Days between infections were extended from 68.2 days (range: 25-82) to 130 days (range: 43-412). Protocol compliance increased from 76.7% (first quarter) to 91.3% (final quarter). Ninety (1.9%) children developed an SWI preprotocol and 64 (1.5%) postprotocol, P = .18. The 657 (15%) delayed sternal closure patients had a 5% infection rate with 18 (5.7%) in year 1 and 14 (4.3%) in year 2 P = .43. Delayed sternal closure patients demonstrated a trend toward increased risk for SWI of 1.046 for each day the sternum remained open, P = .067. Children who received appropriately timed preop antibiotics developed less infections than those who did not, 1.9% versus 4.1%, P = .007. A multicenter QI project to reduce pediatric SWIs demonstrated an extension of days between infections and a decrease in SWIs. Patients who received preop antibiotics on time had lower SWI rates than those who did not.

  19. A single center experience of donation after cardiac death liver transplantation in pediatric recipients.

    PubMed

    Bartlett, Adam; Vara, Roshni; Muiesan, Paolo; Mariott, Paul; Dhawan, Anil; Mieli-Vergani, Giorgina; Rela, Mohamed; Heaton, Nigel

    2010-05-01

    Many centers are now performing DCD adult LT. There has been a reluctance to transplant pediatric recipients with DCD livers due to concern over the medium to long-term outcome. We describe the outcome of 14 children (median age seven yr, 8 months-16 yr) that underwent LT with DCD grafts from July 2001 to December 2007. Donors had a median age of 23 yr (10-64), intensive care stay of five d (2-14) and bilirubin of 9 mmol/L (6-60). Median warm and cold ischemic time was 16 min (11-29) and seven h (5.5-8.4). Livers were transplanted as a whole organ (4), reduced graft (8), formal split (1) or auxiliary transplant (1). Compared to DBD recipients AST was significantly higher on the first three post-operative days and there was no difference in the INR, bilirubin or GGT out to 12 months. There were no biliary or vascular complications and patient and graft survival is 100% at a median follow-up of 41.8 months (1.7-74 months). LT with DCD grafts in pediatric recipients can be performed with low morbidity and excellent short-to-medium term patient and graft outcome.

  20. Interobserver agreement on the echocardiographic parameters that estimate right ventricular systolic function in the early postoperative period of cardiac surgery.

    PubMed

    Olmos-Temois, S G; Santos-Martínez, L E; Álvarez-Álvarez, R; Gutiérrez-Delgado, L G; Baranda-Tovar, F M

    2016-11-01

    To know the variability of transthoracic echocardiographic parameters that assess right ventricular systolic function by analyzing interobserver agreement in the early postoperative period of cardiovascular surgery. To assess the feasibility of these echocardiographic measurements. A cross-sectional study, double-blind pilot study was carried out from May 2011 to February 2013. Cardiovascular postoperative critical care at the National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico. Consecutive, non-probabilistic sampling. Fifty-six patients were studied in the postoperative period of cardiac surgery. The first echocardiographic parameters were obtained between 6-8hours after cardiac surgery, followed by blinded second measurements. Tricuspid annular plane systolic excursion (TAPSE), tricuspid annular peak systolic velocity on tissue Doppler imaging (VSPAT), diameters and right ventricular outflow area, tract fractional shortening. The agreement was analyzed by the Bland-Altman method, and its magnitude was assessed by the intraclass correlation coefficient (95% confidence interval). Both observers evaluated TAPSE and VSPAT in 48 patients (92%). The average TAPSE was 11.68±4.53mm (range 4-27mm). Right ventricular systolic dysfunction was observed in 41 cases (85%) and normal TAPSE in 7 patients (15%). The average difference and its limits according to TAPSE were -0.917±2.95 (-6.821, 4.988), with a magnitude of 0.725 (0.552, 0.837); the tricuspid annular peak systolic velocity on tissue Doppler imaging was -0.001±0.015 (-0.031, 0.030), and its magnitude 0.825 (0.708, 0.898), respectively. VSPAT and TAPSE were estimated by both observers in 92% of the patients, these parameters exhibiting the lowest interobserver variability. Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

  1. Early postoperative care of liver transplantation for infants with biliary atresia during pediatric intensive care unit stay.

    PubMed

    Guo, C-B; Li, Y-C; Zhang, M-M; Yan, L-N; Pu, C-L; Kang, Q; Jin, X-Q

    2010-06-01

    The aim of this study was to present our institutional experience with the pediatric intensive care unit (PICU) stays of liver recipients to understand prevention of complications. This retrospective review included 22 infants who weighed 8.8 kg or less and underwent 23 transplantations. No grafts were from executed prisoners. We summarized the diagnosis, evaluation, medicine usage, and therapeutic intervention associated with subjects experiencing complications of rejection episodes, surgery, or infection during their ICU stay. There was one perioperative death from primary graft nonfunction. The most common postoperative complications were infections, gastrointestinal bleeding, and vascular complications. Rejection episodes occurred among 25% of patients. The most common isolated pathogenic bacteria was Staphylococcus epidermidis. Median initial ICU stay was 10 days. Mean requirement for artificial ventilation was 37.6 hour. Mean times of use of dobutamine, prostaglandin E1, and dopamine was 3.3, 7.5, and 8.8 days, respectively. Parenteral nutrition was started at a mean of 12 hours and oral food intake at a mean of 72 hours. Although challenging, orthotopic liver transplantation (OLT) in small infants can be successfully performed with meticulous surgical technique and keen postoperative surveillance.

  2. Four-Group Classification Based on Fibrinogen Level and Fibrin Polymerization Associated With Postoperative Bleeding in Cardiac Surgery.

    PubMed

    Kawashima, Shingo; Suzuki, Yuji; Sato, Tsunehisa; Kikura, Mutsuhito; Katoh, Takasumi; Sato, Shigehito

    2016-10-01

    Fibrinogen and fibrin formation have a key role in perioperative hemostasis. The aim of this study is to examine the association of postoperative hemostasis with a combined evaluation of the fibrinogen level and fibrin polymerization in cardiac surgery. We retrospectively classified 215 consecutive cardiac surgery patients into 4 groups (Fuji-san classification) that were divided by fibrinogen level <150 mg/dL (ie, hypofibrinogenemia) and fibrinogen thromboelastometry value at 10 minutes with rotational thromboelastometry <6 mm (ie, low fibrin polymerization) at the warming of cardiopulmonary bypass. Four groups resulted; group I, the acceptable range (n = 85); group II, only hypofibrinogenemia (<150 mg/dL, ≥6 mm, n = 63); group III, hypofibrinogenemia and low fibrin polymerization (<150 mg/dL, <6 mm, n = 60); and group IV, only low fibrin polymerization (≥150 mg/dL, <6 mm, n = 7). The risk of chest tube drainage volume greater than 500 mL within the first 24 hours after surgery (with group I as the reference) was increased in group II (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.5-7.4; P < .01) and group III (OR, 8.5; 95% CI, 3.5-21.7; P < .01), and the risk greater than 1000 mL (with group I as the reference) was increased in group III (OR, 4.0; 95% CI, 1.1-17.3; P = .03) and group IV (OR, 23.1; 95% CI, 3.2-201.0; P < .01). Intraoperative blood transfusions were decreased by 24.5%, after stratifying the starting amount of fresh frozen plasma by the 4-group classification in the recent consecutive 65 (30.2%) patients (P < .01). The 4-group classification is associated with postoperative bleeding and may improve the quality of perioperative blood transfusion in cardiac surgery.

  3. Intrathecal Morphine Plus General Anesthesia in Cardiac Surgery: Effects on Pulmonary Function, Postoperative Analgesia, and Plasma Morphine Concentration

    PubMed Central

    dos Santos, Luciana Moraes; Santos, Verônica Cavani Jorge; Santos, Silvia Regina Cavani Jorge; Malbouisson, Luiz Marcelo Sá; Carmona, Maria José Carvalho

    2009-01-01

    OBJECTIVES: To evaluate the effects of intrathecal morphine on pulmonary function, analgesia, and morphine plasma concentrations after cardiac surgery. INTRODUCTION: Lung dysfunction increases morbidity and mortality after cardiac surgery. Regional analgesia may improve pulmonary outcomes by reducing pain, but the occurrence of this benefit remains controversial. METHODS: Forty-two patients were randomized for general anesthesia (control group n=22) or 400 μg of intrathecal morphine followed by general anesthesia (morphine group n=20). Postoperative analgesia was accomplished with an intravenous, patient-controlled morphine pump. Blood gas measurements, forced vital capacity (FVC), forced expiratory volume (FEV), and FVC/FEV ratio were obtained preoperatively, as well as on the first and second postoperative days. Pain at rest, profound inspiration, amount of coughing, morphine solicitation, consumption, and plasma morphine concentration were evaluated for 36 hours postoperatively. Statistical analyses were performed using the repeated measures ANOVA or Mann-Whiney tests (*p<0.05). RESULTS: Both groups experienced reduced FVC postoperatively (3.24 L to 1.38 L in control group; 2.72 L to 1.18 L in morphine FEV1 (p=0.085), group), with no significant decreases observed between groups. The two groups also exhibited similar results for FEV1/FVC (p=0.68) and PaO2/FiO2 ratio (p=0.08). The morphine group reported less pain intensity (evaluated using a visual numeric scale), especially when coughing (18 hours postoperatively: control group= 4.73 and morphine group= 1.80, p=0.001). Cumulative morphine consumption was reduced after 18 hours in the morphine group (control group= 20.14 and morphine group= 14.20 mg, p=0.037). The plasma morphine concentration was also reduced in the morphine group 24 hours after surgery (control group= 15.87 ng.mL−1 and morphine group= 4.08 ng.mL−1, p=0.029). CONCLUSIONS: Intrathecal morphine administration did not significantly alter

  4. Early Lactate Elevations Following Resuscitation From Pediatric Cardiac Arrest Are Associated With Increased Mortality

    PubMed Central

    Topjian, Alexis A.; Clark, Amy E.; Casper, T. Charles; Berger, John T.; Schleien, Charles L.; Dean, J. Michael; Moler, Frank W.

    2014-01-01

    Objective To describe the association of lactate levels within the first 12 hours after successful resuscitation from pediatric cardiopulmonary arrest with hospital mortality. Design Retrospective cohort study. Setting Fifteen children’s hospital associated with the Pediatric Emergency Care Applied Research Network. Patients Patients between 1 day and 18 years old who had a cardiopulmonary arrest, received chest compressions more than 1 minute, had a return of spontaneous circulation more than 20 minutes, and had lactate measurements within 6 hours of arrest. Interventions None. Measurements and Main Results Two hundred sixty-four patients had a lactate sampled between 0 and 6 hours (lactate0–6) and were evaluable. Of those, 153 patients had a lactate sampled between 7 and 12 hours (lactate7–12). One hundred thirty-eight patients (52%) died. After controlling for arrest location, total number of epinephrine doses, initial rhythm, and other potential confounders, the odds of death per 1 mmol/L increase in lactate 0–6 was 1.14 (1.08, 1.19) (p < 0.001) and the odds of death per 1 mmol/L increase in lactate7–12 was 1.20 (1.11, 1.30) (p < 0.0001). Area under the curve for in-hospital arrest mortality for lactate0–6 was 0.72 and for lactate7–12 was 0.76. Area under the curve for out-of-hospital arrest mortality for lactate0–6 was 0.8 and for lactate7–12 was 0.75. Conclusions Elevated lactate levels in the first 12 hours after successful resuscitation from pediatric cardiac arrest are associated with increased mortality. Lactate levels alone are not able to predict outcomes accurately enough for definitive prognostication but may approximate mortality observed in this large cohort of children’s hospitals. PMID:23925146

  5. Chest physiotherapy fails to prevent postoperative atelectasis in children after cardiac surgery.

    PubMed Central

    Reines, H D; Sade, R M; Bradford, B F; Marshall, J

    1982-01-01

    In a prospective, randomized study, the effectiveness of chest physiotherapy (CPT) was evaluated in preventing postoperative atelectasis in children after heart surgery. Postoperative clinical variables and chest x-ray findings of atelectasis were compared in two groups: 19 patients receiving CPT and 25 patients not receiving CPT (NCPT). Chest physiotherapy was associated with significantly more frequent (p less than 0.01) and more severe (p less than 0.01) atelectasis than NCPT. Atelectasis was not significantly associated with temperature elevation, age, or presence of preoperative left-to-right shunt. Images Fig. 1. PMID:7039528

  6. Vasoactive Drugs and Hemodynamic Monitoring in Pediatric Cardiac Intensive Care: An Italian Survey.

    PubMed

    Rizza, Alessandra; Bignami, Elena; Belletti, Alessandro; Polito, Angelo; Ricci, Zaccaria; Isgrò, Giuseppe; Locatelli, Alessandro; Cogo, Paola

    2016-01-01

    Little is known about practitioner preference, the availability of technology, and variability in practice with respect to hemodynamic monitoring and vasoactive drug use after congenital heart surgery. The aim of this study was to characterize current hospital practices related to the management of low cardiac output syndrome (LCOS) across Italy. We issued a 22-item questionnaire to 14 Italian hospitals performing pediatric cardiac surgery. Electrocardiogram, invasive blood pressure, central venous pressure, pulse oximetry, diuresis, body temperature, arterial lactate, and blood gas analysis were identified as routine in hemodynamic monitoring. With regard to advanced hemodynamic monitoring, pulmonary arterial catheter and transpulmonary thermodilution were available in 43% of the centers, uncalibrated pulse contour methods in 29% of the centers, and transesophageal/transthoracic echocardiograms in all of the centers. Dopamine added to milrinone was the most frequent drug regimen for LCOS prevention after cardiopulmonary bypass. Overall, 86% of centers used milrinone alone as the initial treatment for LCOS with elevated systemic vascular resistances and levosimendan, the second preferred choice. In cases of LCOS with low vascular resistance, epinephrine was the first choice (10 centers), dopamine was the second choice (4 centers), followed by vasopressin and norepinephrine (3 centers). For treatment of LCOS with elevated pulmonary resistances, milrinone was the first choice (eight centers), followed by inhaled nitric oxide (five centers). The survey shows that advanced hemodynamic monitoring is rarely performed. The most commonly used vasoactive drugs are milrinone, levosimendan, dopamine, epinephrine, vasopressin, and norepinephrine. Guidelines on the topic are warranted. © The Author(s) 2015.

  7. Shockable rhythms and defibrillation during in-hospital pediatric cardiac arrest.

    PubMed

    Rodríguez-Núñez, Antonio; López-Herce, Jesús; del Castillo, Jimena; Bellón, José María

    2014-03-01

    To analyze the results of cardiopulmonary resuscitation (CPR) that included defibrillation during in-hospital cardiac arrest (IH-CA) in children. A prospective multicenter, international, observational study on pediatric IH-CA in 12 European and Latin American countries, during 24 months. Data from 502 children between 1 month and 18 years were collected using the Utstein template. Patients with a shockable rhythm that was treated by electric shock(s) were included. The primary endpoint was survival at hospital discharge. Univariate logistic regression analysis was performed to find outcome factors. Forty events in 37 children (mean age 48 months, IQR: 7-15 months) were analyzed. An underlying disease was present in 81.1% of cases and 24.3% had a previous CA. The main cause of arrest was a cardiac disease (56.8%). In 17 episodes (42.5%) ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) was the first documented rhythm, and in 23 (57.5%) it developed during CPR efforts. In 11 patients (27.5%) three or more shocks were needed to achieve defibrillation. Return of spontaneous circulation (ROSC) was obtained in 25 cases (62.5%), that was sustained in 20 (50.0%); however only 12 children (32.4%) survived to hospital discharge. Children with VF/pVT as first documented rhythm had better sustained ROSC (64.7% vs. 39.1%, p=0.046) and survival to hospital discharge rates (58.8% vs. 21.7%, p=0.02) than those with subsequent VF/pVT. Survival rate was inversely related to duration of CPR. Clinical outcome was not related to the cause or location of arrest, type of defibrillator and waveform, energy dose per shock, number of shocks, or cumulative energy dose, although there was a trend to better survival with higher doses per shock (25.0% with <2Jkg(-1), 43.4% with 2-4Jkg(-1) and 50.0% with >4Jkg(-1)) and worse with higher number of shocks and cumulative energy dose. The termination of pediatric VF/pVT in the IH-CA setting is achieved in a low percentage of

  8. Elevated cranial ultrasound resistive indices are associated with improved neurodevelopmental outcomes one year after pediatric cardiac surgery: A single center pilot study.

    PubMed

    Jenks, Christopher L; Hernandez, Ana; Stavinoha, Peter L; Morris, Michael C; Tian, Fenghua; Liu, Hanli; Garg, Parvesh; Forbess, Joseph M; Koch, Joshua

    To determine if a non-invasive, repeatable test can be used to predict neurodevelopmental outcomes in patients with congenital heart disease. This was a prospective study of pediatric patients less than two months of age undergoing congenital heart surgery at the Children's Health Children's Medical Center at Dallas. Multichannel near-infrared spectroscopy (NIRS) was utilized during the surgery, and ultrasound (US) resistive indices (RI) of the major cranial vessels were obtained prior to surgery, immediately post-operatively, and prior to discharge. Pearson's correlation, Fischer exact t test, and Fischer r to z transformation were used where appropriate. A total of 16 patients were enrolled. All had US data. Of the sixteen patients, two died prior to the neurodevelopmental testing, six did not return for the neurodevelopmental testing, and eight patients completed the neurodevelopmental testing. There were no significant correlations between the prior to surgery and prior to discharge US RI and neurodevelopmental outcomes. The immediate post-operative US RI demonstrated a strong positive correlation with standardized neurodevelopmental outcome measures. We were able to demonstrate qualitative differences using multichannel NIRS during surgery, but experienced significant technical difficulties implementing consistent monitoring. A higher resistive index in the major cerebral blood vessels following cardiac surgery in the neonatal period is associated with improved neurological outcomes one year after surgery. Obtaining an ultrasound with resistive indices of the major cerebral vessels prior to and after surgery may yield information that is predictive of neurodevelopmental outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

  9. The effect of two different doses of remifentanil on postoperative pain and opioid consumption after cardiac surgery--a randomized controlled trial.

    PubMed

    Florkiewicz, P; Musialowicz, T; Pitkänen, O; Lahtinen, P

    2015-09-01

    Remifentanil, an ultra-short-acting opioid, provides intensive analgesia without prolonged respiratory depression and is widely used in cardiac surgery. Diminished dosing may also offer stable hemodynamics, even during sternotomy and sternal retraction. However, increased postoperative pain and induced opioid tolerance after remifentanil dosing during abdominal surgery was reported. We tested whether remifentanil 0.3 μg/kg/min infusion increased postoperative opioid consumption and pain compared to 0.1 μg/kg/min dosing. Ninety coronary artery bypass grafting or heart valve surgery patients were randomized to remifentanil 0.1 μg/kg/min or 0.3 μg/kg/min infusions during surgery. All patients received oxycodone bolus 0.15 μg/kg postoperatively, and patient-controlled analgesia (PCA) with oxycodone thereafter. Postoperative pain was estimated thrice daily by visual analogue scale, and 48-h opioid consumption was recorded from the PCA-device. Total remifentanil dosing was 64 μg/kg in the higher and 22 μg/kg in the lower dosing group during the 3-h cardiac operations. Mean postoperative opioid consumption was 107 (SD 36) mg in the lower and 104 (SD 33) mg in the higher dose remifentanil groups. Postoperative pain did not differ between groups, at rest or during deep breathing, at any time (P = 0.110 and 0.941, respectively). Remifentanil 0.3 μg/kg/min infusion did not increase postoperative pain or opioid consumption after cardiac surgery compared to the 0.1 μg/kg/min infusion. Remifentanil infusion 0.1-0.3 μg/kg/min during cardiac surgery was safe, with no exaggerated postoperative pain or opioid consumption. © 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

  10. Cost-effectiveness analysis of acute kidney injury biomarkers in pediatric cardiac surgery.

    PubMed

    Petrovic, Stanislava; Bogavac-Stanojevic, Natasa; Lakic, Dragana; Peco-Antic, Amira; Vulicevic, Irena; Ivanisevic, Ivana; Kotur-Stevuljevic, Jelena; Jelic-Ivanovic, Zorana

    2015-01-01

    Acute kidney injury (AKI) is significant problem in children with congenital heart disease (CHD) who undergo cardiac surgery. The economic impact of a biomarker-based diagnostic strategy for AKI in pediatric populations undergoing CHD surgery is unknown. The aim of this study was to perform the cost effectiveness analysis of using serum cystatin C (sCysC), urine neutrophil gelatinase-associated lipocalin (uNGAL) and urine liver fatty acid-binding protein (uL-FABP) for the diagnosis of AKI in children after cardiac surgery compared with current diagnostic method (monitoring of serum creatinine (sCr) level). We developed a decision analytical model to estimate incremental cost-effectiveness of different biomarker-based diagnostic strategies compared to current diagnostic strategy. The Markov model was created to compare the lifetime cost associated with using of sCysC, uNGAL, uL-FABP with monitoring of sCr level for the diagnosis of AKI. The utility measurement included in the analysis was quality-adjusted life years (QALY). The results of the analysis are presented as the incremental cost-effectiveness ratio (ICER). Analysed biomarker-based diagnostic strategies for AKI were cost-effective compared to current diagnostic method. However, uNGAL and sCys C strategies yielded higher costs and lower effectiveness compared to uL-FABP strategy. uL-FABP added 1.43 QALY compared to current diagnostic method at an additional cost of $8521.87 per patient. Therefore, ICER for uL-FABP compared to sCr was $5959.35/QALY. Our results suggest that the use of uL-FABP would represent cost effective strategy for early diagnosis of AKI in children after cardiac surgery.

  11. Impact of dialysis adequacy on cardiac function in pediatric CAPD patients.

    PubMed

    Bakkaloğlu, S A; Ekim, M; Koçak, G; Atalay, S; Tümer, N

    2001-01-01

    Left ventricular hypertrophy is a major cause of morbidity and mortality among patients with chronic renal failure. Uremia-related risk factors play a fundamental role in its occurrence, thus better prognosis and prolonged survival can be attained by successful dialytic therapies. To investigate whether dialysis adequacy has a beneficial effect on cardiac structure and function in children receiving continuous ambulatory peritoneal dialysis (CAPD). Cross-sectional study in the Pediatric Peritoneal Dialysis Unit of a university hospital. Eighteen children, aged 13.3 +/- 2.8 years, being treated with CAPD, and 20 healthy age- and sex-matched control subjects were enrolled in this study. Echocardiographic evaluation was performed in all subjects. Dialysis adequacy indices [weekly urea (Kt/V) and creatinine clearance (TCCr)] were calculated in the dialysis group. Interventricular septal thickness, left ventricular (LV) posterior wall thickness, LV mass index (LVMI), and LV end systolic and diastolic dimensions were all found to be significantly higher in the CAPD group compared to the control subjects (p < 0.01). Ejection fraction and fractional shortening of the LV were not significantly different between the two groups. Mean Kt/V was 2.02 +/- 0.71 and mean TCCr was 58 +/- 33 L/wk/1.73 m2. There were significant negative correlations between dialysis adequacy indices and LV end systolic and diastolic dimensions (p < 0.05 and p < 0.001). Ejection fraction and fractional shortening were positively correlated with Kt/V (p < 0.01). Systolic and diastolic blood pressures were positively correlated with LVMI (r= 0.501 and r = 0.523). Significant inverse correlations between mean arterial pressure and both Kt/V and TCCr (r = -0.555 and r = -0.520) were detected. These data clearly document that cardiac structure and function are remarkably influenced by the uremic state and dialysis therapy in pediatric CAPD patients. The close relationships between echocardiographic

  12. Age-Dependent Effect of Pediatric Cardiac Progenitor Cells After Juvenile Heart Failure

    PubMed Central

    Agarwal, Udit; Smith, Amanda W.; French, Kristin M.; Boopathy, Archana V.; George, Alex; Trac, David; Brown, Milton E.; Shen, Ming; Jiang, Rong; Fernandez, Janet D.; Kogon, Brian E.; Kanter, Kirk R.; Alsoufi, Baahaldin; Wagner, Mary B.; Platt, Manu O.

    2016-01-01

    Children with congenital heart diseases have increased morbidity and mortality, despite various surgical treatments, therefore warranting better treatment strategies. Here we investigate the role of age of human pediatric cardiac progenitor cells (hCPCs) on ventricular remodeling in a model of juvenile heart failure. hCPCs isolated from children undergoing reconstructive surgeries were divided into 3 groups based on age: neonate (1 day to 1 month), infant (1 month to 1 year), and child (1 to 5 years). Adolescent athymic rats were subjected to sham or pulmonary artery banding surgery to generate a model of right ventricular (RV) heart failure. Two weeks after surgery, hCPCs were injected in RV musculature noninvasively. Analysis of cardiac function 4 weeks post-transplantation demonstrated significantly increased tricuspid annular plane systolic excursion and RV ejection fraction and significantly decreased wall thickness and fibrosis in rats transplanted with neonatal hCPCs compared with saline-injected rats. Computational modeling and systems biology analysis were performed on arrays and gave insights into potential mechanisms at the microRNA and gene level. Mechanisms including migration and proliferation assays, as suggested by computational modeling, showed improved chemotactic and proliferative capacity of neonatal hCPCs compared with infant/child hCPCs. In vivo immunostaining further suggested increased recruitment of stem cell antigen 1-positive cells in the right ventricle. This is the first study to assess the role of hCPC age in juvenile RV heart failure. Interestingly, the reparative potential of hCPCs is age-dependent, with neonatal hCPCs exerting the maximum beneficial effect compared with infant and child hCPCs. Significance Stem cell therapy for children with congenital heart defects is moving forward, with several completed and ongoing clinical trials. Although there are studies showing how children differ from adults, few focus on the differences

  13. Post-operative bleeding risk stratification in cardiac pulmonary bypass patients using artificial neural network.

    PubMed

    Huang, Richard S P; Nedelcu, Elena; Bai, Yu; Wahed, Amer; Klein, Kimberly; Tint, Hlaing; Gregoric, Igor; Patel, Manish; Kar, Biswajit; Loyalka, Pranav; Nathan, Sriram; Radovancevic, Rajko; Nguyen, Andy N D

    2015-01-01

    The prediction of bleeding risk in cardiopulmonary bypass (CPB) patients plays a vital role in their postoperative management. Therefore, an artificial neural network (ANN) to analyze intra-operative laboratory data to predict postoperative bleeding was set up. The JustNN software (Neural Planner Software, Cheshire, England) was used. This ANN was trained using 15 intra-operative laboratory parameters paired with one output category - risk of bleeding, defined as units of blood components transfused in 48 hours. The ANN was trained with the first 39 CPB cases. The set of input parameters for this ANN was also determined, and the ANN was validated with the next 13 cases. The set of input parameters include five components: pro-thrombin time, platelet count, thromboelastograph-reaction time, D-Dimer, and thromboelastograph-coagulation index. The validation results show 9 cases (69.2%) with exact match, 3 cases (23.1%) with one-grading difference, and 1 case (7.7%) with two-grading difference between actual blood usage versus predicted blood usage. To the best of our knowledge, ours is the first ANN developed for post-operative bleeding risk stratification of CPB patients. With promising results, we have started using this ANN to risk-stratify our CPB patients, and it has assisted us in predicting post-operative bleeding risk. © 2015 by the Association of Clinical Scientists, Inc.

  14. Preoperative Cognitive Performance and Postoperative Delirium Are Independently Associated With Future Dementia in Older People Who Have Undergone Cardiac Surgery: A Longitudinal Cohort Study.

    PubMed

    Lingehall, Helena Claesson; Smulter, Nina S; Lindahl, Elisabeth; Lindkvist, Marie; Engström, Karl Gunnar; Gustafson, Yngve G; Olofsson, Birgitta

    2017-08-01

    To investigate if postoperative delirium was associated with the development of dementia within 5 years after cardiac surgery. Longitudinal cohort study. Cardiothoracic Division, Umeå University Hospital, Sweden. Patients aged 70 years old or older (n = 114) scheduled for routine cardiac procedures with cardiopulmonary bypass without documented dementia were enrolled in 2009. Structured assessments were performed preoperatively, 1 and 4 days after extubation, and 1, 3, and 5 years postoperatively. Patients were assessed comprehensively, including cognitive and physical function, coexisting medical conditions, demographic characteristics, and medications. Diagnoses of delirium, depression, and dementia were made according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criteria. During the 5-year period, 30 of 114 participants (26.3%) developed dementia. Postoperative delirium had occurred in 87% of those who later developed dementia. A multivariable logistic regression model showed a lower preoperative Mini-Mental State Examination score (p < 0.001; odds ratio, 0.68; 95% CI, 0.54-0.84) and the occurrence of postoperative delirium (p = 0.002; odds ratio, 7.57; 95% CI, 2.15-26.65) were associated with dementia occurrence. Our findings suggest that older patients with reduced preoperative cognitive functions or who develop postoperative delirium are at risk of developing dementia within 5 years after cardiac surgery. Cognitive functions should be screened for preoperatively, those who develop postoperative delirium should be followed up to enable early detection of dementia symptoms, and management should be implemented.

  15. Plasma Neutrophil Gelatinase-Associated Lipocalin and Acute Postoperative Kidney Injury in Adult Cardiac Surgical Patients

    PubMed Central

    Perry, Tjörvi E.; Muehlschlegel, Jochen D.; Liu, Kuang-Yu; Fox, Amanda A.; Collard, Charles D.; Shernan, Stanton K.; Body, Simon C.

    2010-01-01

    BACKGROUND Acute kidney injury (AKI) after coronary artery bypass graft (CABG) surgery is associated with increased postoperative morbidity and mortality. We hypothesized that increased plasma neutrophil gelatinase-associated lipocalin (NGAL) measured immediately after separating from cardiopulmonary bypass (CPB) would predict AKI after CABG surgery. METHODS In a retrospective observational study, we examined the value of plasma NGAL measured after CPB for predicting the risk of developing AKI (defined as a ≥50% increase in serum creatinine from preoperative levels) in 879 patients after CABG surgery using multivariable logistic regression. Area under the curve of receiver operating characteristic curves was analyzed to assess sensitivities, specificities, and cutoff points for postoperative plasma NGAL levels to predict AKI. RESULTS Seventy-five patients (8.6%) developed postoperative AKI. Plasma NGAL levels measured after CPB were higher in patients who subsequently developed AKI than in those who did not (AKI: 268.8 ng/mL [207.5–459.5 ng/mL], median [interquartile range], vs no AKI: 238.4 ng/mL [172.0–319.1 ng/mL]; P < 0.001) and remained higher through postoperative day 4. An optimal serum plasma NGAL cutoff of 353.5 ng/mL at the post-CPB time point had a sensitivity of 38.7%, specificity of 81.5%, and a positive predictive value of 16.3% for predicting AKI. In our multivariate regression model, post-CPB plasma NGAL levels >353.5 ng/mL were independently associated with postoperative AKI (odds ratio, 2.3; 95% confidence interval, 1.5–6.5; P = 0.002). CONCLUSION An early increase of post-CPB plasma NGAL is associated with AKI in adult patients undergoing CABG surgery, although the sensitivity is low. Therefore, assessing early plasma NGAL alone has limited utility for predicting AKI in this patient population. PMID:20435938

  16. [THE DIAGNOSTIC AND THERAPEUTIC BRONCHOSCOPY IN CARDIAC PATIENTS UNDERGOING MECHANICAL VENTILATION IN THE POSTOPERATIVE PERIOD].

    PubMed

    Titova, I V; Khrustaleva, M V; Eremenko, A A; Babaev, M A

    2016-01-01

    The review presents an analysis of domestic and foreign literature on the use of bronchoscopy in patients with obstructive respiratory failure in the ICU. Separately considered the issue of additional research when performing bronchoscopy and create an algorithmfor the application of diagnostic and therapeutic bronchoscopy in cardiac surgical patients undergoing mechanical ventilation.

  17. Intrathecal Morphine Versus Extended-Release Epidural Morphine for Postoperative Pain Control in Pediatric Patients Undergoing Posterior Spinal Fusion.

    PubMed

    Cohen, Mindy; Zuk, Jeannie; McKay, Nancy; Erickson, Mark; Pan, Zhaoxing; Galinkin, Jeffrey

    2017-06-01

    Posterior spinal fusion for scoliosis is one of the most painful elective pediatric surgeries. Good postoperative pain control allows early ambulation and return of ability to tolerate oral intake. Options for analgesia in this patient population are suboptimal. We hypothesized that extended-release epidural morphine (EREM) would provide better pain control and less adverse effects compared to intrathecal (IT) morphine. The primary outcome was total IV morphine consumption during 0-48 hours postoperatively. Secondary outcomes included time until first patient-controlled analgesia (PCA) demand, pain scores, and adverse opioid effects. After institutional review board approval, 71 subjects undergoing posterior spinal fusion for idiopathic scoliosis completed the study. The subjects were randomly allocated to 7.5 μg/kg IT morphine or 150 μg/kg EREM. The final IT morphine and EREM groups contained 37 and 34 subjects, respectively. Postoperative pain was treated with morphine PCA, ketorolac, oral oxycodone, and acetaminophen. Morphine consumption, pain scores, nausea and vomiting, pruritus, and respiratory depression were measured every 4 hours. Parents completed a caregiver questionnaire about their child's pain control regimen after the first postoperative day. There was no difference in total morphine consumption over the first 48 hours between subjects in the EREM and IT morphine groups: median (range) 42.2 (5.5-123.0) and 34.0 (4.5-128.8) mg, respectively (P = .27). EREM and IT morphine groups had no difference in time until first PCA demand. Pain scores were no different between the groups from 8 to 24 hours after surgery. Compared to IT morphine, EREM subjects had lower pain scores from 28 to 36 hours after surgery. The reported incidence of pruritus was lower in the EREM subjects. There was no difference in total morphine consumption or time until first PCA demand between the EREM and IT morphine groups. EREM provides a longer duration of analgesia after

  18. Postoperative Conversion Disorder Presenting as Inspiratory Stridor and Hemiparesis in a Pediatric Patient

    PubMed Central

    Nelson, Erik J.; Wu, Jennifer Y.

    2017-01-01

    Patient: Female, 13 Final Diagnosis: Postoperative conversion disorder Symptoms: Right-sided weakness and right-sided sensory loss • difficulty speaking Medication: — Clinical Procedure: EUS/EGD Specialty: Anesthesiology Objective: Rare co-existance of disease or pathology Background: Postoperative conversion disorder is rare and has been reported. The diagnosis is usually made after all major organic causes have been ruled out. Case Report: We describe a case of a 13-year-old female who presented in the post-anesthesia care unit with acute-onset inspiratory stridor and unresponsiveness to verbal or painful stimuli after receiving a general anesthetic for upper endoscopy. Later in the post-anesthesia care unit, she presented with acute-onset right hemiplegia and sensory loss. She was first evaluated for causes of her stridor and unresponsiveness. The evaluation revealed paradoxical vocal cord movement, and all laboratory test values were normal. For her hemiplegia and sensory loss, she was evaluated for stroke with head MRI and CT scans, which were normal. Conclusions: After extensive workup and consideration of multiple etiologies for her presenting signs and symptoms, the most likely diagnosis was conversion disorder. PMID:28093564

  19. Role of C1q complement fixing antibody assay in therapeutic plasma exchange management of pediatric cardiac antibody mediated rejection.

    PubMed

    Onwuemene, Oluwatoyosi A; Heath, Deneen M; Hartman, Carol; Wong, Edward C C

    2017-08-01

    Pediatric cardiac transplant patients with antibody-mediated rejection (AMR) often undergo therapeutic plasma exchange (TPE) to remove pathologic donor specific antibodies (DSA). In cases where DSA persist, it is unclear how long TPE should be continued. We report a case of a 17-year-old cardiac transplant patient with AMR where use of a C1q complement fixing antibody assay helped guide TPE cessation. This report adds to the existing literature that highlights the potential clinical significance of C1q antibodies in AMR management. © 2016 Wiley Periodicals, Inc.

  20. Stratification of pediatric heart failure on the basis of neurohormonal and cardiac autonomic nervous activities in patients with congenital heart disease.

    PubMed

    Ohuchi, Hideo; Takasugi, Hisashi; Ohashi, Hiroyuki; Okada, Yoko; Yamada, Osamu; Ono, Yasuo; Yagihara, Toshikatsu; Echigo, Shigeyuki

    2003-11-11

    Stratification of pediatric patients with congenital heart disease (CHD) has been based on their hemodynamics and/or functional capacity. Our purpose was to compare cardiac autonomic nervous activity (CANA) and neurohormonal activities (NHA) with postoperative status in stable CHD patients with biventricular physiology. We divided 379 subjects (297 CHD patients, 28 dilated cardiomyopathy patient, and 54 control subjects) into 4 subgroups according to New York Heart Association (NYHA) class (1.3+/-0.7) and measured various CANA and NHA indices. Stepwise decreases in baroreflex sensitivity (BRS), heart rate variability (HRV), adrenergic imaging, and vital capacity (VC) were observed in proportion to functional capacity in normal to NYHA II patients (P<0.001). However, there were no differences in these indices between NYHA II and III+IV groups, whereas a stepwise proportional increase in NHA indices was observed in these groups (P<0.001). Natriuretic peptides differentiated all NYHA classes. BRS, HRV, and VC were greater in the adult patients than in the child patients (P<0.05 to 0.01), although the functional class in adult patients was lower. Cardiac surgeries resulted in low BRS and VC, and the VC reduction independently determined a small HRV. Even if functional class and ejection fraction were comparable, CANA and brain natriuretic peptide were lower in CHD patients than in dilated cardiomyopathy patients (P<0.05 to 0.001). CANA and NHA indices are useful to stratify mild and severe heart failure in stable postoperative CHD patients, respectively. However, careful attention should be paid to age- and surgery-related influences on these indices.

  1. Long-term prognostic value of cardiac autonomic nervous activity in postoperative patients with congenital heart disease.

    PubMed

    Ohuchi, Hideo; Negishi, Jun; Miyake, Akira; Sakaguchi, Heima; Miyazaki, Aya; Yamada, Osamu

    2011-09-15

    Abnormal cardiac autonomic nervous activity (CANA) is not uncommon in postoperative patients with congenital heart disease (CHD). We attempted to clarify the prognostic value of the CANA variables in postoperative CHD patients and prospectively evaluated the CANA variables in 292 consecutive biventricular and 91 Fontan repair patients. The CANA variables included the heart rate variability, arterial baroreflex sensitivity (BRS), washout ratio of the myocardial metaiodobenzylguanidine scintigraphy, and plasma norepinephrine level. With a follow-up of 10 ± 2 years, 98 total events that required hospitalization, including 13 deaths and 48 unscheduled cardiac events (UCEs), occurred. In all the CHD patients, all the CANA indices predicted the total events and UCEs. Of those, the NE level (p=0.0004) and BRS (p=0.0373) predicted the mortality. In a multivariate analysis, the BRS was an independent CANA-predictor for the total events (p=0.007). In the biventricular patients, the plasma NE level, heart rate variability, and BRS predicted the total events and UCEs and the BRS was the only independent CANA-predictor for the total events (p=0.0329). In the Fontan patients, the plasma NE level was the only predictor for the UCEs (p=0.0242) and no other CANA variables were independent predictors of the total events or UCEs. All CANA variables, especially the BRS, were useful predictors for future clinical events in biventricular CHD patients, whereas no CANA variables, except for the plasma NE level, predicted future clinical events in the Fontan patients. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

  2. Use of Cardiac Computed Tomography for Ventricular Volumetry in Late Postoperative Patients with Tetralogy of Fallot

    PubMed Central

    Kim, Ho Jin; Mun, Da Na; Goo, Hyun Woo; Yun, Tae-Jin

    2017-01-01

    Background Cardiac computed tomography (CT) has emerged as an alternative to magnetic resonance imaging (MRI) for ventricular volumetry. However, the clinical use of cardiac CT requires external validation. Methods Both cardiac CT and MRI were performed prior to pulmonary valve implantation (PVI) in 11 patients (median age, 19 years) who had undergone total correction of tetralogy of Fallot during infancy. The simplified contouring method (MRI) and semiautomatic 3-dimensional region-growing method (CT) were used to measure ventricular volumes. Results All volumetric indices measured by CT and MRI generally correlated well with each other, except for the left ventricular end-systolic volume index (LV-ESVI), which showed the following correlations with the other indices: the right ventricular end-diastolic volume index (RV-EDVI) (r=0.88, p<0.001), the right ventricular end-systolic volume index (RV-ESVI) (r=0.84, p=0.001), the left ventricular end-diastolic volume index (LV-EDVI) (r=0.90, p=0.001), and the LV-ESVI (r=0.55, p=0.079). While the EDVIs measured by CT were significantly larger than those measured by MRI (median RV-EDVI: 197 mL/m2 vs. 175 mL/m2, p=0.008; median LV-EDVI: 94 mL/m2 vs. 92 mL/m2, p=0.026), no significant differences were found for the RV-ESVI or LV-ESVI. Conclusion The EDVIs measured by cardiac CT were greater than those measured by MRI, whereas the ESVIs measured by CT and MRI were comparable. The volumetric characteristics of these 2 diagnostic modalities should be taken into account when indications for late PVI after tetralogy of Fallot repair are assessed. PMID:28382264

  3. Postoperative Conversion Disorder Presenting as Inspiratory Stridor and Hemiparesis in a Pediatric Patient.

    PubMed

    Nelson, Erik J; Wu, Jennifer Y

    2017-01-17

    BACKGROUND Postoperative conversion disorder is rare and has been reported. The diagnosis is usually made after all major organic causes have been ruled out. CASE REPORT We describe a case of a 13-year-old female who presented in the post-anesthesia care unit with acute-onset inspiratory stridor and unresponsiveness to verbal or painful stimuli after receiving a general anesthetic for upper endoscopy. Later in the post-anesthesia care unit, she presented with acute-onset right hemiplegia and sensory loss. She was first evaluated for causes of her stridor and unresponsiveness. The evaluation revealed paradoxical vocal cord movement, and all laboratory test values were normal. For her hemiplegia and sensory loss, she was evaluated for stroke with head MRI and CT scans, which were normal. CONCLUSIONS After extensive workup and consideration of multiple etiologies for her presenting signs and symptoms, the most likely diagnosis was conversion disorder.

  4. Incidence of inferior vena cava thrombosis detected by transthoracic echocardiography in the immediate postoperative period after adult cardiac and general surgery.

    PubMed

    Saranteas, T; Kostopanagiotou, G; Tzoufi, M; Drachtidi, K; Knox, G M; Panou, F

    2013-11-01

    Venous thromboembolism is an important complication after general and cardiac surgery. Using transthoracic echocardiography, this study assessed the incidence of inferior vena cava (IVC) thrombosis among a total of 395 and 289 cardiac surgical and major surgical patients in the immediate postoperative period after cardiac and major surgery, respectively. All transthoracic echocardiography was performed by a specialist intensivist within 24 hours after surgery with special emphasis on using the subcostal view in the supine position to visualise the IVC. Of the 395 cardiac surgical patients studied, the IVC was successfully visualised using the subcostal view in 315 patients (79.8%) and eight of these patients (2.5%) had a partially obstructive thrombosis in the IVC. In 250 out of 289 (85%) general surgical patients, the IVC was also clearly visualised, but only one patient (0.4%) had an IVC thrombosis (2.5 vs 0.4%, P <0.05). In summary, visualisation of the IVC was feasible in most patients in the immediate postoperative period after both adult cardiac and major surgery. IVC thrombosis appeared to be more common after adult cardiac surgery than general surgery. A large prospective cohort study is needed to define the risk factors for IVC thrombus and whether early thromboprophylaxis can reduce the incidence of IVC thrombus after adult cardiac surgery.

  5. Intracranial Ependymomas in Children: Society of Pediatric Oncology Experience With Postoperative Hyperfractionated Local Radiotherapy

    SciTech Connect

    Conter, Cecile Carrie, Christian; Bernier, Valerie; Geoffray, Anne; Pagnier, Anne; Gentet, Jean-Claude; Lellouch-Tubiana, Arielle; Chabaud, Sylvie; Frappaz, Didier

    2009-08-01

    Purpose: To prospectively investigate the role of local hyperfractionated radiotherapy (RT) after surgical resection in the treatment of intracranial ependymomas in children. Patients and Methods: Postoperative local hyperfractionated RT was proposed for every child (>5 years old at diagnosis) with localized intracranial ependymoma. The planned dose was 60 Gy after complete resection (CR) and 66 Gy after partial resection, delivered in two daily fractions of 1 Gy, according to the early postoperative imaging findings. Results: Between November 1996 and December 2002, 24 children with infratentorial (n = 20) or supratentorial (n = 4) intracranial ependymoma were included. The median age was 8.6 years (range, 5-17). The World Health Organization grade was anaplastic in 10 of the 24 patients (not assessable in 1). After a retrospective central review, a CR was reported in 16 patients, partial resection in 4, and doubtful resection in 4. The radiation dose was 60 Gy in 18 cases (one partial resection), 66 Gy in 5 cases (one CR), and 54 Gy in 1 case (CR). The 5-year overall survival rate was 74.8%, and the progression-free survival rate was 54.2%. Of the 24 patients, 11 developed a relapse: 7 local only and 4 metastatic and local. The histological grade and extent of resection were not prognostic factors. More than 3 in 4 children had no sequelae of RT at a median follow-up of 7 years (95% confidence interval, 66.4-90.0 months). Conclusion: The results of our study have shown that hyperfractionated RT is safe but provides no outcome benefit compared with other strategies of RT such as standard fractionated regimens.

  6. [Pediatric lung resection. A case series and evaluation of postoperative lung function].

    PubMed

    Caussade, S; Zúñiga, S; García, C; González, S; Campos, E; Soto, G; Zúñiga, F; Sánchez, I

    2001-12-01

    The most common causes of pulmonary lobectomy in children are congenital lung malformations (CLM) and bronchiectasias. Our aim was to present the causes and clinical course and lung function of lobectomized patients. Between 1990 and July 1999 27 lobectomies were performed on patients whose ages ranged from newborn to 14 years. Lobectomies were performed to correct CLM in 124 cases and for acquired pulmonary disease (APD) in 13. Among CLM cases, half (n = 7) had cystic adenomatoid malformation. Among the APD patients, 10 had bronchiectasias, with etiological confirmation in 6 cases (3 secondary to serious adenovirus infection). Mean hospital stay was 4.6 days among those who experienced no postoperative complications. Symptoms resolved after surgery for most symptomatic patients. Lung function tests could be carried out with 8 patients over 6 years old whose operations had taken place 7 to 78 months earlier (x = 35 months) and whose age at the time of surgery was a mean 7 years 6 months (range 60 to 144 months). Spirometry showed normal forced vital capacity for 7 of 8 patients (87 to 143% of theoretical value). Arterial oxygen saturation measured during and after a 6-minute walking test was normal for 7 of 8 patients. Chest films showed reduced lung volume on the affected side in 5 of 8 patients. In summary, lobectomy is a procedure with few complications. It requires a short hospital stay and has good postoperative prognosis. Function and x-ray studies show adequate lung growth and development, with normal lung function in those who could be so examined because they were old enough to cooperate.

  7. Influence of circulating levels of fibrinogen and perioperative coagulation parameters on predicting postoperative blood loss in cardiac surgery: a prospective observational study.

    PubMed

    Pillai, Ravi C; Fraser, John F; Ziegenfuss, Marc; Bhaskar, Balu

    2014-03-01

    Fibrinogen, the major clotting protein in blood plasma, plays key roles in blood coagulation and thrombosis. In this prospective cohort study, we measured patient's fibrinogen levels and common coagulation parameters before and after cardiopulmonary bypass (CPB) and examined their relationships with postoperative blood loss. Patients undergoing cardiac surgery with CPB who did not have pre-existing coagulopathy were eligible. Standard blood and coagulation testing were performed before and after CPB. The association of these variables with postoperative blood loss (estimated blood loss from CPB) was assessed with Spearman's ranked correlation and multivariable linear regression models. Two hundred and fifty patients were enrolled in the study. The median blood loss was 780 mL (range 320-2340 mL). Variables independently associated with increasing blood loss were lower post-CPB platelet counts (p<0.001), lower postoperative fibrinogen levels (p<0.001), and larger percent decrease in fibrinogen levels (p<0.05). There was no correlation between preoperative fibrinogen levels and preoperative coagulation tests with postoperative bleeding. The only significant independent predictors of transfusion in a logistic regression model were postoperative fibrinogen concentration. Postoperative fibrinogen, the larger percent decrease in fibrinogen, and postoperative platelet levels are markers of bleeding and blood transfusion requirements after CPB than preoperative standard screening tests. Postoperative fibrinogen had the best predictive value of all tests of postoperative blood loss.

  8. Decreased Bioenergetic Health Index in monocytes isolated from the pericardial fluid and blood of post-operative cardiac surgery patients.

    PubMed

    Kramer, Philip A; Chacko, Balu K; George, David J; Zhi, Degui; Wei, Chih-Cheng; Dell'Italia, Louis J; Melby, Spencer J; George, James F; Darley-Usmar, Victor M

    2015-07-01

    Monitoring the bioenergetics of leucocytes is now emerging as an important approach in translational research to detect mitochondrial dysfunction in blood or other patient samples. Using the mitochondrial stress test, which involves the sequential addition of mitochondrial inhibitors to adherent leucocytes, we have calculated a single value, the Bioenergetic Health Index (BHI), which represents the mitochondrial function in cells isolated from patients. In the present report, we assess the BHI of monocytes isolated from the post-operative blood and post-operative pericardial fluid (PO-PCF) from patients undergoing cardiac surgery. Analysis of the bioenergetics of monocytes isolated from patients' PO-PCF revealed a profound decrease in mitochondrial function compared with monocytes isolated from their blood or from healthy controls. Further, patient blood monocytes showed no significant difference in the individual energetic parameters from the mitochondrial stress test but, when integrated into the BHI evaluation, there was a significant decrease in BHI compared with healthy control monocytes. These data support the utility of BHI measurements in integrating the individual parameters from the mitochondrial stress test into a single value. Supporting our previous finding that the PO-PCF is pro-oxidant, we found that exposure of rat cardiomyocytes to PO-PCF caused a significant loss of mitochondrial membrane potential and increased reactive oxygen species (ROS). These findings support the hypothesis that integrated measures of bioenergetic health could have prognostic and diagnostic value in translational bioenergetics.

  9. Factors associated with excessive postoperative blood loss and hemostatic transfusion requirements: a multivariate analysis in cardiac surgical patients.

    PubMed

    Despotis, G J; Filos, K S; Zoys, T N; Hogue, C W; Spitznagel, E; Lappas, D G

    1996-01-01

    The purpose of this study was to prospectively evaluate whether heparin and protamine doses administered using a standardized protocol based on body weight and activated clotting time values are associated with either transfusion of hemostatic blood products (HBPs) or excessive postoperative bleeding. Analysis using 10 multiple logistic or linear regression models in 487 cardiac surgical patients included perioperative variables that may have an association with either transfusion of HBP and/or excessive postoperative chest tube drainage (CTD). Prolonged duration of cardiopulmonary bypass (CPB), lower pre-CPB heparin dose, lower core body temperature in the intensive care unit, combined procedures, older age, repeat procedures, a larger volume of salvaged red cells reinfused intraoperatively and abnormal laboratory coagulation results (prothrombin time, activated partial thromboplastin time, and platelet count) after CPB were associated with both transfusion of HBP and increased CTD. Female gender, lower total heparin dose, preoperative aspirin use and the number of HBPs administered intraoperatively were associated only with increased CTD, whereas a larger total protamine dose was associated only with perioperative transfusion of HBPs. Preoperative use of warfarin or heparin was not associated with excessive blood loss of perioperative transfusion of HBPs. In contrast to previous studies using bovine heparin, data from the present study do not support the use of reduced doses of porcine heparin during CPB.

  10. Preoperative Antihypertensive Medication in Relation to Postoperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery: A Meta-Analysis

    PubMed Central

    Zhou, Ai-Guo; Chen, An-ji; Zhang, Xiong-fei; Deng, Hui-wei

    2017-01-01

    Background. We undertake a systematic review and meta-analysis to evaluate the effect of preoperative hypertension and preoperative antihypertensive medication to postoperative atrial fibrillation (POAF) in patients undergoing cardiac surgery. Methods. We searched PubMed, Embase, and Cochrane Library (from inception to March 2016) for eligible studies. The outcomes were the effects of preoperative hypertension, preoperative calcium antagonists regimen, preoperative ACE inhibitors regimen, and preoperative beta blocking agents regimen with POAF. We calculated pooled risk ratios (OR) and 95% CIs using random- or fixed-effects models. Results. Twenty-five trials involving 130087 patients were listed. Meta-analysis showed that the number of preoperative hypertension patients in POAF group was significantly higher (P < 0.05), while we found that there are no significant differences between two groups in Asia patients by subgroup analysis, which is in contrast to other outcomes. Compared with the Non-POAF group, the number of patients who used calcium antagonists and ACE inhibitors preoperatively in POAF group was significantly higher (P < 0.05). And we found that there were no significant differences between two groups of preoperative beta blocking agents used (P = 0.08). Conclusions. Preoperative hypertension and preoperative antihypertensive medication in patients undergoing cardiac operations seem to be associated with higher risk of POAF. PMID:28286753

  11. Early Post-Operative Outcomes and Blood Product Utilization in Adult Cardiac Surgery- The Post Aprotinin Era

    PubMed Central

    DeSantis, Stacia; Toole, J. Matthew; Kratz, John M.; Uber, Walter E.; Wheat, Margaret J.; Stroud, Martha R.; Ikonomidis, John S.; Spinale, Francis G.

    2011-01-01

    Background Aprotinin was a commonly utilized pharmacological agent for homeostasis in cardiac surgery but was discontinued resulting in the extensive use of lysine analogues. This study tested the hypothesis that early post-operative adverse events and blood product utilization would affected in this post-aprotinin era. Methods/Results Adult patients (n=781) undergoing coronary artery bypass (CABG), valve replacement, or both from November 1, 2005-October 31, 2008 at a single institution were included. Multiple logistic regression modeling and propensity scoring were performed on 29 pre-operative and intra-operative variables in patients receiving aprotinin (n=325) or lysine analogues (n=456). The propensity adjusted relative risk (RR;95% confidence interval;CI) for the intra-operative use of packed red blood cells (RR:0.75;CI:0.57–0.99), fresh frozen plasma (RR:0.37;0.21–0.64), and cryoprecipitate (RR:0.06;CI:0.02–0.22) were lower in the aprotinin versus lysine analogue group (all p<0.05). The risk for mortality (RR:0.53;CI:0.16–1.79) and neurological events (RR:0.87;CI:0.35–2.18) remained similar between groups, whereas a trend for reduced risk for renal dysfunction was observed in the aprotinin group. Conclusions In the post-aprotinin era with the exclusive use of lysine analogues, the relative risk of early post-operative outcomes such as mortality and renal dysfunction have not improved, but the risk for the intra-operative use of blood products has increased. Thus, improvements in early post-operative outcomes have not been realized with the discontinued use of aprotinin, but rather increased blood product utilization has occurred with the attendant costs and risks inherent with this strategy. PMID:21911820

  12. The influence of perioperative coagulation status on postoperative blood loss in complex cardiac surgery: a prospective observational study.

    PubMed

    Karkouti, Keyvan; McCluskey, Stuart A; Syed, Summer; Pazaratz, Chris; Poonawala, Humara; Crowther, Mark A

    2010-06-01

    Coagulopathy leading to excessive blood loss is a serious complication of cardiac surgery. In this prospective cohort study, we measured patients' coagulation status before and after cardiopulmonary bypass (CPB) and examined their relationships with postoperative blood loss. Patients undergoing complex cardiac surgery with CPB who did not have preexisting coagulopathy were eligible. Detailed clinical and coagulation data were prospectively collected on all patients. Coagulation testing was performed before and after CPB, and included measures of thrombin generation, clotting factor consumption and dilution, clot stabilization, and fibrinolysis. The associations of variables with post-CPB blood loss (estimated loss from CPB to intensive care unit admission and 24-hour chest tube drainage) were assessed with the Spearman rank correlation test and multivariable linear regression. The median blood loss among the 101 study patients was 952 mL (interquartile range, 601-1553 mL). Variables independently associated with increasing blood loss were as follows: previous sternotomies (P = 0.01), lower pre-CPB prothrombin fragment F1 + 2 levels (measure of thrombin generation; P = 0.001), lower post-CPB platelet counts (P = 0.01), larger percent decrease in fibrinogen levels (P = 0.05), and higher post-CPB soluble fibrin monomer levels (measure of thrombin activity and clot stabilization; P < 0.0001) (model R(2) = 0.43). In complex cardiac surgery, blood loss is directly influenced by reduced pre-CPB thrombin generation rate, increased post-CPB consumption and dilution of clotting factors, as well as inadequate post-CPB clot stabilization. This information can aid in identifying patients at high risk for excessive blood loss and testing new interventions aimed at reducing the burden of this complication. The validity and generalizability of these findings need to be assessed by other studies.

  13. The Coagulative Profile of Cyanotic Children Undergoing Cardiac Surgery: The Role of Whole Blood Preoperative Thromboelastometry on Postoperative Transfusion Requirement.

    PubMed

    Vida, Vladimiro L; Spiezia, Luca; Bortolussi, Giacomo; Marchetti, Marta E; Campello, Elena; Pittarello, Demetrio; Gregori, Dario; Stellin, Giovanni; Simioni, Paolo

    2016-07-01

    The objective of this study is to evaluate the preoperative coagulation pattern and its association to postoperative blood products transfusion in children with congenital heart disease (CHD), focusing on cyanotic patients (oxygen saturation, SATO 2  < 85%). From January to August 2014, preoperative standard coagulation tests and rotational thromboelastometry assays were performed on 81 pediatric patients (<16 years old) who underwent surgery for CHD with the aid of cardiopulmonary bypass. Sixty patients (74%) were acyanotic and 21 (26%) cyanotic. Mean age at time of surgery was 7.9 months (interquartile range 2.9-43.6 months). Cyanotic patients had a significantly higher hematocrit (P < 0.001), a reduced prothrombin activity (PT) (P = 0.01) level, and a lower platelet count (P = 0.02) than acyanotic patients. An inverse linear association was found between patient's SATO2 and clot formation time (CFT) (INTEM, P = 0.001, and EXTEM, P < 0.0001). A direct linear association was found between patient's SATO2 and maximum clot firmness (MCF) (INTEM, P = 0.04, and EXTEM, P = 0.05). Preoperative cyanosis was also associated with a lower median MCF in FIBTEM (P = 0.02). Cyanotic patients required more frequent postoperative transfusions of fibrinogen (7/21 patients, 33% vs. 4/60 patients, 6.7%, P = 0.01) and fresh frozen plasma (14/21, 67% vs. 25/60, 42%, P = 0.08). Patients with a lower presurgery PT and platelet count subsequently required more fibrinogen transfusion P = 0.02 and P = 0.003, respectively); the same goes for patients with a longer CFT (INTEM, P = 0.01 and EXTEM, P = 0.03) and a reduced MCF (INTEM, P = 0.02 and FIBTEM, P = 0.01) as well. Cyanotic patients showed significant preoperative coagulation anomalies and required a higher postoperative fibrinogen supplementation. The preoperative MCF FIBTEM has become an important factor in our postoperative thromboelastometry-guided transfusion

  14. The correlation between preoperative erythrocyte sedimentation rate and postoperative outcome in adult cardiac surgery

    PubMed Central

    Bilehjani, Eissa; Fakhari, Solmaz; Farzin, Haleh; Yaghoubi, Alireza; Mirinazhad, Moussa; Shadvar, Kamran; Dehghani, Abbasali; Aboalaiy, Pariasadat

    2017-01-01

    Introduction Over the past decades, it has been recommended that preoperative assessment mainly relies on history and physical examination rather than unnecessary laboratory tests. In Iranian hospitals, erythrocyte sedimentation rate (ESR) has been routinely measured in most of the patients awaiting major surgery, which has in turn exacted heavy costs on the health system. Therefore, the aim of the present study was to assess the preoperative routine measurement of ESR in such patients. Materials and methods This is a retrospective study, in which we evaluated the medical files of 620 patients. Patients older than 18 years, who had undergone elective heart surgery in our hospital in 2014, were included in the study. The data associated with demography, heart disease diagnosis, type of surgery, significant preoperative tests, delay or postponing of surgery and the reason for it, type and characteristics of the subspecialty consultation, and finally, postoperative complication and mortality rate were collected and analyzed. The patients were categorized into four groups according to ESR value: normal (<15 mm/h in females or <20 mm/h in males), moderately increased (<40 mm/h), severely increased (≥40 mm/h), and not measured. Results Of the 620 patients’ files, 402 were of males and 218 were of females. Demographic values and preoperative characteristics were similar in the four groups. A total of 105 consultations were given to 79 patients preoperatively, where only in five cases, the elevation in ESR was the main reason for consultation. In no other cases did the consultations result in new diagnoses. Overall, postoperative complication and mortality rate were the same in all four groups; in severely increased ESR group, on the other hand, the need for long periods of intensive care unit (ICU) and hospital stays was higher than that of other groups. Conclusion It is concluded that elevated preoperative ESR does not cancel or defer the surgery, nor does it help

  15. Use of pediatric Berlin Heart EXCOR biventricular device as a bridge to retransplantation in a 10-month-old infant with acute graft failure after cardiac transplantation.

    PubMed

    Krokstrom, Ann-Katrin; Higgins, Thomas; Johansson, Sune; Jögi, Peeter

    2009-01-01

    We report the implantation of the Berlin Heart EXCOR (Berlin Heart, Berlin, Germany) as a pediatric biventricular assist device in a 10-month-old boy with primary graft failure after cardiac transplantation. The EXCOR was successfully used as a bridge to cardiac retransplantation. The pneumatically driven paracorporeal device supported the patient for 165 days until another suitable heart was obtained.

  16. Data integrity of the Pediatric Cardiac Critical Care Consortium (PC4) clinical registry

    PubMed Central

    Gaies, Michael; Donohue, Janet E.; Willis, Gina M.; Kennedy, Andrea T.; Butcher, John; Scheurer, Mark A.; Alten, Jeffrey A.; Gaynor, J. William; Schuette, Jennifer J.; Cooper, David S.; Jacobs, Jeffrey P.; Pasquali, Sara K.; Tabbutt, Sarah

    2015-01-01

    Background Clinical databases in congenital and paediatric cardiac care provide a foundation for quality improvement, research, policy evaluations and public reporting. Structured audits verifying data integrity allow database users to be confident in these endeavours. We report on the initial audit of the Pediatric Cardiac Critical Care Consortium (PC4) clinical registry. Materials and methods Participants reviewed the entire registry to determine key fields for audit, and defined major and minor discrepancies for the audited variables. In-person audits at the eight initial participating centres were conducted during a 12-month period. The data coordinating centre randomly selected intensive care encounters for review at each site. The audit consisted of source data verification and blinded chart abstraction, comparing findings by the auditors with those entered in the database. We also assessed completeness and timeliness of case submission. Quantitative evaluation of completeness, accuracy, and timeliness of case submission is reported. Results We audited 434 encounters and 29,476 data fields. The aggregate overall accuracy was 99.1%, and the major discrepancy rate was 0.62%. Across hospitals, the overall accuracy ranged from 96.3 to 99.5%, and the major discrepancy rate ranged from 0.3 to 0.9%; seven of the eight hospitals submitted >90% of cases within 1 month of hospital discharge. There was no evidence for selective case omission. Conclusions Based on a rigorous audit process, data submitted to the PC4 clinical registry appear complete, accurate, and timely. The collaborative will maintain ongoing efforts to verify the integrity of the data to promote science that advances quality improvement efforts. PMID:26358157

  17. Radiation exposure in children during the current era of pediatric cardiac intervention.

    PubMed

    El Sayed, Maiy Hamdy; Roushdy, Alaa Mahmoud; El Farghaly, Hala; El Sherbini, Ahmad

    2012-01-01

    Cardiac catheterizations are among the X-ray procedures with the highest patient radiation dose and therefore are of great concern in pediatric settings. This study aimed to evaluate factors that influence variability of X-ray exposure in children with congenital heart diseases during cardiac catheterization. The study included 107 children who underwent either diagnostic (n = 46) or interventional (n = 61) procedures. A custom-made sheet for patient and procedural characteristics was designed. Data were collected, and different correlations were applied to determine factors that influence variability of X-ray exposure. The fluoroscopy time (FT) differed significantly between the diagnostic (8.9 ± 6.3 min) and intervention (12.8 ± 9.98 min) groups (P = 0.032). The mean dose-area product (DAP) differed significantly between the two groups (3.775 ± 2.5 Gy/cm(2) vs. 13.239 ± 15.4 Gy/cm(2); P = 0.003). The highest DAP was during left anterior oblique (LAO) cranial 30° angulation (2.8 Gy/cm(2)/4 s cine). The mean cumulative dose (CD) was 0.053 Gy in diagnostic cases and 0.48 Gy in intervention cases. The effective dose was 5.97 ± 7.05 mSv for therapeutic procedures compared with 3.42 ± 3.64 mSv for diagnostic procedures. The FT correlated significantly with both the DAP (r = 0.718; P < 0.001) and the CD (r = 0.701; P < 0.001). Other correlations were reported. An increasing number of therapeutic catheterization procedures are being performed for children. The justification for these procedures is evident because they avoid complicated surgery. However, the complexity of these procedures results in higher radiation exposures.

  18. [Psychiatric pathology after extracorporeal cardiac surgery: a case report of tardive postoperative cognitive dysfunction].

    PubMed

    Hernández Fleta, J L; Uría Rivera, T; Santamarína Montila, S; Serrano Quintana, I

    1998-01-01

    A 67-year-old female patient operated of a severe aortic esthenosis with extracorporeal circulation during cardiac surgery, developed psychiatric disturbances with excitement and delirium, being necessary internamtient in a psychiatric ward, a month later. The evolution was right after neuroleptic treatment and nowdays she's assimptomatic. We review what is wrote about posteparative cognitive dysfunction (POCD), being this a tardive presentation case. We analize the definition, prevalence, etiology, pathofisiology, treatment and prevention since it is a reversible surgery complication but if it isn't early diagnosed and treated, its morbidity and mortality can be high.

  19. A comparison of postoperative emergence agitation between sevoflurane and thiopental anesthesia induction in pediatric patients

    PubMed Central

    Son, Ji-Seon; Jang, Eunjoo; Oh, Min Wook; Lee, Ji-Hye; Han, Young Jin

    2015-01-01

    Background This study was performed to compare the incidence of emergence agitation (EA) between inhalation and intravenous anesthesia induction in children after sevoflurane anesthesia. Methods In this prospective and double-blind study, 100 children aged 3 to 7 years were enrolled. Subjects were randomly assigned to the sevoflurane (Group S) or thiopental (Group T) anesthesia induction groups. Anesthesia was induced using 8% sevoflurane and 4-6 mg/kg thiopental in Groups S and T, respectively. Anesthesia was maintained with nitrous oxide and sevoflurane. The children were evaluated at 5 and 20 min after arrival in the postanesthesia care unit (PACU) with a four-point agitation scale and the Pediatric Anesthesia Emergence Delirium scale. The incidence of EA and administration of the rescue agent were recorded. Results The incidence of EA was significantly lower in Group T compared to Group S at 5 min after PACU arrival (3/49 patients, 6% vs. 12/47 patients, 26%, P = 0.019). However, there was no difference between the two groups at 20 min after PACU arrival (23/49 vs. 19/47 patients in Group T vs. Group S, P = 0.425). The overall incidence of EA was 60% (28/47 patients) in Group S and 41% (20/49 patients) in Group T (P = 0.102). The number of children who received propofol as a rescue agent was significantly lower in Group T (Group S: 14/47 vs. Group T: 5/49, P = 0.031). Conclusions Intravenous anesthesia induction with thiopental reduced the incidence of EA in the early PACU period compared to inhalation induction with sevoflurane in 3- to 7-year-old children undergoing sevoflurane anesthesia. PMID:26257850

  20. Evaluation of closed-loop anesthesia delivery for propofol anesthesia in pediatric cardiac surgery.

    PubMed

    Biswas, Indranil; Mathew, Preethy J; Singh, Rana S; Puri, Goverdhan D

    2013-12-01

    The objective of this study was to compare the feasibility of closed-loop anesthesia delivery with manual control of propofol in pediatric patients during cardiac surgery. Forty ASA II-III children, undergoing elective cardiac surgery under cardiopulmonary bypass (CPB) in a tertiary care hospital, were randomized to receive propofol either through a closed-loop anesthesia delivery system (CL group) or through traditional manual control (manual group) to achieve a target BIS of 50. Patients were induced and subsequently maintained with a propofol infusion. The propofol usage and the efficacy of closed-loop system in controlling BIS within ±10 of the target were compared with that of manual control. The maintenance of BIS within ±10 of target and intraoperative hemodynamic stability were similar between the two groups. However, induction dose of propofol was less in the CL group (2.06 ± 0.79 mg·kg(-1) ) than the manual group (2.95 ± 1.03 mg·kg(-1) ) (P = 0.006) with less overshoot of BIS during induction in the closed-loop group (P = 0.007). Total propofol used in the off-CPB period was less in the CL group (6.29 ± 2.48 mg·kg(-1) h(-1) vs 7.82 ± 2.1 mg·kg(-1) h(-1) ) (P = 0.037). Phenylephrine use in the pre-CPB period was more in the manual group (16.92 ± 10.92 μg·kg(-1) vs 5.79 ± 5.98 μg·kg(-1) ) (P = 0.014). Manual group required a median of 18 (range 8-29) dose adjustments per hour, while the CL group required none. This study demonstrated the feasibility of closed-loop controlled propofol anesthesia in children, even in challenging procedures such as cardiac surgery. Closed-loop system needs further and larger evaluation to establish its safety and efficacy. © 2013 John Wiley & Sons Ltd.

  1. Improving pediatric cardiac surgical care in developing countries: matching resources to needs.

    PubMed

    Dearani, Joseph A; Neirotti, Rodolfo; Kohnke, Emily J; Sinha, Kingshuk K; Cabalka, Allison K; Barnes, Roxann D; Jacobs, Jeffrey P; Stellin, Giovanni; Tchervenkov, Christo I; Cushing, John C

    2010-01-01

    This article reviews a systematic approach to the design and support of pediatric cardiac surgery programs in the developing world with the guidance and strategies of Children's HeartLink, an experienced non-government organization for more than 40 years. An algorithm with criteria for the selection of a partner site is outlined. A comprehensive education strategy from the physician to the allied health care provider is the mainstay for successful program development. In a partner program, the road to successful advancement and change depends on many factors, such as government support, hospital administration support, medical staff leadership, and a committed and motivated faculty with requisite skills, incentives, and resources. In addition to these factors, it is essential that the development effort includes considerations of environment (eg, governmental support, regulatory environment, and social structure) and health system (elements related to affordability, access, and awareness of care) that impact success. Partner programs should be willing to initiate a clinical database with the intent to analyze and critique their results to optimize quality assurance and improve outcomes. Copyright (c) 2010 Elsevier Inc. All rights reserved.

  2. Radiation exposure of pediatric patients and physicians during cardiac catheterization and balloon pulmonary valvuloplasty.

    PubMed

    Wu, J R; Huang, T Y; Wu, D K; Hsu, P C; Weng, P S

    1991-07-15

    Thermoluminescent dosimeters were applied to various areas of 61 pediatric patients and physicians to measure radiation doses during routine cardiac catheterization and during 4 cases of balloon pulmonary valvuloplasty. Radiation doses were measured during chest roentgenography, fluoroscopy and cineangiography. Average skin dose to the chest was 121 microGy during chest x-ray, 5,182 microGy during catheterization and 641 mGy during valvuloplasty. For the eyes, thyroid and gonads of the patients, the exposure during routine catheterization was equal to 0.4, 6 and 0.2 chest x-rays, respectively. Radiation dose of the operator was 3 microGy for the eyes and 6 miCroGy in the thyroid. About 56% of the operator's dose could be reduced by thyroid shields, and 80% by lead aprons. The assistant received only 1 microGy outside the thyroid shield. Therefore, we have concluded that the patients' dose during routine catheterization is largely based on our experimental results, but the dose is acceptable based on the risk factor analysis. The skin dose to the right lateral chest of the patient during valvuloplasty is extremely high, perhaps as high as the equivalent of 1,000 chest x-rays. Besides the clinical benefits of valvuloplasty, the long-term radiation-related hazards to the patient should be carefully monitored.

  3. Cardiac output and associated left ventricular hypertrophy in pediatric chronic kidney disease.

    PubMed

    Weaver, Donald J; Kimball, Thomas R; Koury, Phillip R; Mitsnefes, Mark M

    2009-03-01

    A significant number of children with chronic kidney disease (CKD) have eccentric left ventricular hypertrophy (LVH), suggesting the role of preload overload. Therefore, we hypothesized that increased cardiac output (CO) might be a contributing factor for increased left ventricular mass index (LVMI) in these children. Patients aged 6-20 years with CKD stages 2-4 were enrolled. Echocardiograms were performed to assess LV function and geometry at rest and during exercise. Heart rate, stroke volume, and CO were also assessed at rest and during exercise. Twenty-four-hour ambulatory blood pressure (AMBP) monitoring was performed. Of the patients enrolled in this study, 17% had LVH. Increased stroke volume and CO were observed in patients with LVH compared to patients without LVH. Univariate analysis revealed significant positive associations between LVMI and CO, stroke volume, body mass index, pulse pressure from mean 24-h AMBP, and mean 24-h systolic BP load. No association with heart rate, age, parathyroid hormone, glomerular filtration rate, or anemia was observed. Only CO (beta = 1.98, p = 0.0005) was independently associated with increased LVMI in multivariate modeling (model R (2) = 0.25). The results of this study suggest that increased CO might predispose to increased LVMI in pediatric patients with CKD. Adaptations may be required to meet increased metabolic demand in these patients.

  4. Variation in Outcomes for Risk-Stratified Pediatric Cardiac Surgical Operations: An Analysis of the STS Congenital Heart Surgery Database

    PubMed Central

    Jacobs, Jeffrey Phillip; O'Brien, Sean M.; Pasquali, Sara K.; Jacobs, Marshall Lewis; Lacour-Gayet, François G.; Tchervenkov, Christo I.; Austin III, Erle H.; Pizarro, Christian; Pourmoghadam, Kamal K.; Scholl, Frank G.; Welke, Karl F.; Gaynor, J. William; Clarke, David R.; Mayer, John E.; Mavroudis, Constantine

    2013-01-01

    Background. We evaluated outcomes for groups of risk-stratified operations in The Society of Thoracic Surgeons Congenital Heart Surgery Database to provide contemporary benchmarks and examine variation between centers. Methods. Patients undergoing surgery from 2005 to 2009 were included. Centers with more than 10% missing data were excluded. Discharge mortality and postoperative length of stay (PLOS) among patients discharged alive were calculated for groups of risk-stratified operations using the five Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery mortality categories (STAT Mortality Categories). Power for analyzing between-center differences in outcome was determined for each STAT Mortality Category. Variation was evaluated using funnel plots and Bayesian hierarchical modeling. Results. In this analysis of risk-stratified operations, 58,506 index operations at 73 centers were included. Overall discharge mortality (interquartile range among programs with more than 10 cases) was as follows: STAT Category 1 = 0.55% (0% to 1.0%), STAT Category 2 = 1.7% (1.0% to 2.2%), STAT Category 3 = 2.6% (1.1% to 4.4%), STAT Category 4 = 8.0% (6.3% to 11.1%), and STAT Category 5 = 18.4% (13.9% to 27.9%). Funnel plots with 95% prediction limits revealed the number of centers characterized as outliers by STAT Mortality Categories was as follows: Category 1 = 3 (4.1%), Category 2 = 1 (1.4%), Category 3 = 7 (9.7%), Category 4 = 13 (17.8%), and Category 5 = 13 (18.6%). Between-center variation in PLOS was analyzed for all STAT Categories and was greatest for STAT Category 5 operations. Conclusions. This analysis documents contemporary benchmarks for risk-stratified pediatric cardiac surgical operations grouped by STAT Mortality Categories and the range of outcomes among centers. Variation was greatest for the more complex operations. These data may aid in the design and planning of quality assessment and quality improvement

  5. Effects of perioperative statin treatment on postoperative atrial fibrillation and cardiac mortality in patients undergoing coronary artery bypass grafting: a propensity score analysis.

    PubMed

    Kunt, Ayşegül; Özcan, Sedat; Küçüker, Aslihan; Odabaşi, Dolunay; Sami Kunt, Alper

    2015-08-01

    To evaluate the effect of perioperative statin treatment on postoperative atrial fibrillation and cardiac mortality in patients undergoing coronary artery bypass grafting. A total of 1890 patients who underwent isolated coronary artery bypass were analyzed retrospectively, of which 425 patients (22.4%) older than 70 were included in the study. The demographic properties, preoperative, operative and postoperative data and other medications of these patients were recorded. Continuous preoperative and postoperative atorvastatin therapy were received by 124 (29.17%) patients; 301 (70.82%) patients were matched to a control group (no-statin group). The two groups were matched by propensity score analysis in terms of atrial fibrillation development and cardiac mortality. Medical history, medical treatment, cardiovascular history, and operative characteristics demonstrated significant heterogeneity in both groups. Postoperative atrial fibrillation was similar in both groups. Before propensity score matching, the percentages of patients in postoperative atrial fibrillation with respect to Atorvastain-group and No-statin-group were 13.71 and 10.3 respectively; however, those were 13.71 and 14.51 after matching. In a multivariate regression analysis, five-vessel bypass (odds ratio OR, 2.354; 95% confidence interval CI, 0.99 to 5.57) was an independent predictor of postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting. In-hospital mortality was higher in the Atorvastatin-group compared with the No-statin-group: 124 (8.9%) versus 301 (3.7%), respectively; p=0.027). Perioperative atorvastatin treatment is not found to be associated with reduced postoperative atrial fibrillation and cardiac mortality in patients undergoing isolated coronary artery bypass grafting above the age of seventy years. Copyright© by the Medical Assotiation of Zenica-Doboj Canton.

  6. In-line Filtration Decreases Systemic Inflammatory Response Syndrome, Renal and Hematologic Dysfunction in Pediatric Cardiac Intensive Care Patients.

    PubMed

    Sasse, Michael; Dziuba, Friederike; Jack, Thomas; Köditz, Harald; Kaussen, Torsten; Bertram, Harald; Beerbaum, Philipp; Boehne, Martin

    2015-08-01

    Cardiac surgery with cardiopulmonary bypass (CPB) frequently leads to systemic inflammatory response syndrome (SIRS) with concomitant organ malfunction. Infused particles may exacerbate inflammatory syndromes since they activate the coagulation cascade and alter inflammatory response or microvascular perfusion. In a randomized, controlled, prospective trial, we have previously shown that particle-retentive in-line filtration prevented major complications in critically ill children. Now, we investigated the effect of in-line filtration on major complications in the subgroup of cardiac patients. Children admitted to tertiary pediatric intensive care unit were randomized to either control or filter group obtaining in-line filtration throughout complete infusion therapy. Risk differences and 95 % confidence intervals (CI) of several complications such as SIRS, sepsis, mortality, various organ failure and dysfunction were compared between both groups using the Wald method. 305 children (n = 150 control, n = 155 filter group) with cardiac diseases were finally analyzed. The majority was admitted after cardiac surgery with CPB. Risk of SIRS (-11.3 %; 95 % CI -21.8 to -0.5 %), renal (-10.0 %; 95 % CI -17.0 to -3.0 %) and hematologic (-8.1 %; 95 % CI -14.2 to -0.2 %) dysfunction were significantly decreased within the filter group. No risk differences were demonstrated for occurrence of sepsis, any other organ failure or dysfunctions between both groups. Infused particles might aggravate a systemic hypercoagulability and inflammation with subsequent organ malfunction in pediatric cardiac intensive care patients. Particle-retentive in-line filtration might be effective in preventing SIRS and maintaining renal and hematologic function. In-line filtration offers a novel therapeutic option to decrease morbidity in cardiac intensive care.

  7. Hemoglobin and B-type natriuretic peptide preoperative values but not inflammatory markers, are associated with postoperative morbidity in cardiac surgery: a prospective cohort analytic study

    PubMed Central

    2013-01-01

    Introduction Risk stratification in cardiac surgery significantly impacts outcome. This study seeks to define whether there is an independent association between the preoperative serum level of hemoglobin (Hb), leukocyte count (LEUCO), high sensitivity C-reactive protein (hsCRP), or B-type natriuretic peptide (BNP) and postoperative morbidity and mortality in cardiac surgery. Methods Prospective, analytic cohort study, with 554 adult patients undergoing cardiac surgery in a tertiary cardiovascular hospital and followed up for 12 months. The cohort was distributed according to preoperative values of Hb, LEUCO, hsCRP, and BNP in independent quintiles for each of these variables. Results After adjustment for all covariates, a significant association was found between elevated preoperative BNP and the occurrence of low postoperative cardiac output (OR 3.46, 95% CI 1.53–7.80, p = 0.003) or postoperative atrial fibrillation (OR 3.8, 95% CI 1.45–10.38). For the combined outcome (death/acute coronary syndrome/rehospitalization within 12 months), we observed an OR of 1.93 (95% CI 1.00–3.74). An interaction was found between BNP level and the presence or absence of diabetes mellitus. The OR for non-diabetics was 1.26 (95% CI 0.61–2.60) and for diabetics was 18.82 (95% CI 16.2–20.5). Preoperative Hb was also significantly and independently associated with the occurrence of postoperative low cardiac output (OR 0.33, 95% CI 0.13–0.81, p = 0.016). Both Hb and BNP were significantly associated with the lengths of intensive care unit and hospital stays and the number of transfused red blood cells (p < 0.002). Inflammatory markers, although associated with adverse outcomes, lost statistical significance when adjusted for covariates. Conclusions High preoperative BNP or low Hb shows an association of independent risk with postoperative outcomes, and their measurement could help to stratify surgical risk. The ability to predict the onset of atrial fibrillation or

  8. Quality of sleep in patients undergoing cardiac surgery during the postoperative period in intensive care.

    PubMed

    Navarro-García, M Á; de Carlos Alegre, V; Martinez-Oroz, A; Irigoyen-Aristorena, M I; Elizondo-Sotro, A; Indurain-Fernández, S; Martorell-Gurucharri, A; Sorbet-Amóstegui, M R; Prieto-Guembe, P; Ordoñez-Ortigosa, E; García-Aizpún, Y; García-Ganuza, R

    To describe the quality of sleep of patients undergoing cardiac surgery during the first two nights following surgery and identify some of the factors conditioning the nightly rest of these patients in the Intensive Care Unit. Observational descriptive study based on applying the Richards-Campbell Sleep Questionnaire through a consecutive sample of patients undergoing cardiac surgery with Intensive Care Unit admission. Simultaneously, a questionnaire assessing different environmental factors existing in the unit as possible conditioning of the night's rest was applied. The association between consumption of opioid and sleep quality was studied. Sample of 66 patients with a mean age of 65±11.57 years, of which 73% were men (N=48). The Richards-Campbell sleep questionnaire garnered average scores of 50.33mm (1.st night) and 53.30mm (2.nd night). The main sleep disturbing factors were discomfort with the different devices, 30.91mm and pain, 30.18mm. The problems caused by environmental noise, 27.5mm or through the voices of the professionals, 26.53mm were also elements of nocturnal discomfort. No statistical association was found between sleep and the distance of the patient with respect to the nursing control area or related to opioid analgesics. The quality of sleep during the first two nights of Intensive Care Unit admission was "regular". The environmental factors that conditioned the night-time rest of patients were discomfort, pain and ambient noise. Copyright © 2016 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.

  9. Evaluation of Tricuspid Annular Plane Systolic Excursion Measured with Cardiac Magnetic Resonance Imaging in Pediatric Patients with Tetralogy of Fallot

    PubMed Central

    Soslow, Jonathan H.; Usoro, Emem; Wang, Li; Parra, David A.

    2015-01-01

    Background Aneurysmal dilation of the right ventricular outflow tract complicates assessment of right ventricular function in patients with repaired tetralogy of Fallot. Tricuspid annular plane systolic excursion is commonly used to estimate ejection fraction. We hypothesized that tricuspid annular plane systolic excursion measured by cardiac magnetic resonance imaging approximates global and segmental right ventricular function, specifically right ventricular sinus ejection fraction, in pediatric patients with repaired tetralogy of Fallot. Methods Tricuspid annular plane systolic excursion was measured retrospectively on cardiac magnetic resonance images in 54 patients with repaired tetralogy of Fallot. Values were compared with right ventricular global, sinus, and infundibular ejection fractions. Tricuspid annular plane systolic excursion was: 1) indexed to body surface area, 2) converted into a fractional value, and 3) converted into published pediatric Z-scores. Results Tricuspid annular plane systolic excursion measurements had good agreement between observers. Right ventricular ejection fraction did not correlate with the absolute or indexed tricuspid annular plane systolic excursion and correlated weakly with fractional tricuspid annular plane systolic excursion (r=0.41 and p=0.002). Segmental right ventricular function did not appreciably improve correlation with any of the tricuspid annular plane systolic excursion measures. Pediatric Z-scores were unable to differentiate patients with normal and abnormal right ventricular function. Conclusions Tricuspid annular plane systolic excursion measured on cardiac magnetic resonance imaging correlates poorly with global and segmental right ventricular ejection fraction in pediatric patients with repaired tetralogy of Fallot. Tricuspid annular plane systolic excursion is an unreliable approximation of right ventricular function in this patient population. PMID:26279488

  10. Post-operative benefits of animal-assisted therapy in pediatric surgery: a randomised study.

    PubMed

    Calcaterra, Valeria; Veggiotti, Pierangelo; Palestrini, Clara; De Giorgis, Valentina; Raschetti, Roberto; Tumminelli, Massimiliano; Mencherini, Simonetta; Papotti, Francesca; Klersy, Catherine; Albertini, Riccardo; Ostuni, Selene; Pelizzo, Gloria

    2015-01-01

    Interest in animal-assisted therapy has been fuelled by studies supporting the many health benefits. The purpose of this study was to better understand the impact of an animal-assisted therapy program on children response to stress and pain in the immediate post-surgical period. Forty children (3-17 years) were enrolled in the randomised open-label, controlled, pilot study. Patients were randomly assigned to the animal-assisted therapy-group (n = 20, who underwent a 20 min session with an animal-assisted therapy dog, after surgery) or the standard-group (n = 20, standard postoperative care). The study variables were determined in each patient, independently of the assigned group, by a researcher unblinded to the patient's group. The outcomes of the study were to define the neurological, cardiovascular and endocrinological impact of animal-assisted therapy in response to stress and pain. Electroencephalogram activity, heart rate, blood pressure, oxygen saturation, cerebral prefrontal oxygenation, salivary cortisol levels and the faces pain scale were considered as outcome measures. After entrance of the dog faster electroencephalogram diffuse beta-activity (> 14 Hz) was reported in all children of the animal-assisted therapy group; in the standard-group no beta-activity was recorded (100% vs 0%, p<0.001). During observation, some differences in the time profile between groups were observed for heart rate (test for interaction p = 0.018), oxygen saturation (test for interaction p = 0.06) and cerebral oxygenation (test for interaction p = 0.09). Systolic and diastolic blood pressure were influenced by animal-assisted therapy, though a higher variability in diastolic pressure was observed. Salivary cortisol levels did not show different behaviours over time between groups (p=0.70). Lower pain perception was noted in the animal-assisted group in comparison with the standard-group (p = 0.01). Animal-assisted therapy facilitated rapid recovery in vigilance and activity

  11. Post-Operative Benefits of Animal-Assisted Therapy in Pediatric Surgery: A Randomised Study

    PubMed Central

    Calcaterra, Valeria; Veggiotti, Pierangelo; Palestrini, Clara; De Giorgis, Valentina; Raschetti, Roberto; Tumminelli, Massimiliano; Mencherini, Simonetta; Papotti, Francesca; Klersy, Catherine; Albertini, Riccardo; Ostuni, Selene; Pelizzo, Gloria

    2015-01-01

    Background Interest in animal-assisted therapy has been fuelled by studies supporting the many health benefits. The purpose of this study was to better understand the impact of an animal-assisted therapy program on children response to stress and pain in the immediate post-surgical period. Patients and Methods Forty children (3–17 years) were enrolled in the randomised open-label, controlled, pilot study. Patients were randomly assigned to the animal-assisted therapy-group (n = 20, who underwent a 20 min session with an animal-assisted therapy dog, after surgery) or the standard-group (n = 20, standard postoperative care). The study variables were determined in each patient, independently of the assigned group, by a researcher unblinded to the patient’s group. The outcomes of the study were to define the neurological, cardiovascular and endocrinological impact of animal-assisted therapy in response to stress and pain. Electroencephalogram activity, heart rate, blood pressure, oxygen saturation, cerebral prefrontal oxygenation, salivary cortisol levels and the faces pain scale were considered as outcome measures. Results After entrance of the dog faster electroencephalogram diffuse beta-activity (> 14 Hz) was reported in all children of the animal-assisted therapy group; in the standard-group no beta-activity was recorded (100% vs 0%, p<0.001). During observation, some differences in the time profile between groups were observed for heart rate (test for interaction p = 0.018), oxygen saturation (test for interaction p = 0.06) and cerebral oxygenation (test for interaction p = 0.09). Systolic and diastolic blood pressure were influenced by animal-assisted therapy, though a higher variability in diastolic pressure was observed. Salivary cortisol levels did not show different behaviours over time between groups (p=0.70). Lower pain perception was noted in the animal-assisted group in comparison with the standard-group (p = 0.01). Conclusion Animal-assisted therapy

  12. Quantification of chemotaxis during pediatric cardiac surgery by flow and laser scanning cytometry

    NASA Astrophysics Data System (ADS)

    Tarnok, Attila; Schmid, Joerg W.; Osmancik, Pavel; Lenz, Dominik; Pipek, Michal; Hambsch, Joerg; Gerstner, Andreas O.; Schneider, Peter

    2002-05-01

    Cardiac surgery with cardiopulmonary bypass (CPB) alters the leukocyte composition of the peripheral blood (PB). This response contributes to the sometimes adverse outcome with capillary leakage. Migration of activated cells to sites of inflammation, driven by chemokines is part of this response. In order to determine the chemotactic activity of patients serum during and after surgery we established an assay for PB leukocytes (PBL). PBL from healthy donors were isolated and 250,000 cells were placed into a migration chamber separated by a filter from a second lower chamber filled with patient serum. After incubation cells from top and bottom chamber were removed and stained with a cocktail of monoclonal antibodies for leukocyte subsets and analyzed on a flow cytometer (FCM). Cells at the bottom of the filter belong to the migrating compartment and were quantified by LSC after staining of nucleated cells. Increased chemotactic activity started at onset of anaesthesia followed by a phase of low activity immediately after surgery and a second phase of a high post-operative activity. The in vitro results correlated with results obtained by immunopenotyping of circulating PBL. Manipulation of the chemokine pattern might prove beneficial to prevent extravasation of cells leading to tissue damage. In chemotaxis assays with low amount of available serum the combined use of FCM and Laser Scanning LSC proved as an appropriate analytical tool.

  13. Clinical and Socio-demographic Predictors of Postoperative Vital Exhaustion in Patients after Cardiac Surgery

    PubMed Central

    Miller, Pamela S.; Evangelista, Lorraine S.; Giger, Joyce Newman; Dracup, Kathleen; Doering, Lynn V.

    2015-01-01

    Background Vital exhaustion, a psychological state characterized by extreme fatigue, is an independent predictor of future cardiac events. However, the attributes of vital exhaustion following coronary artery bypass (CABG) surgery are poorly understood. Objective The study objective was to assess correlates of vital exhaustion following CABG surgery. Methods In a descriptive, exploratory study, 42 patients who had CABG surgery were evaluated for exhaustion four to eight weeks post-hospital discharge. Demographic and clinical data were obtained from self-report and medical chart review. Results Of the total sample (mean age 67.9±12.5, 90% male, 70% Caucasian, 3.12±1.3 grafts), approximately 41% reported exhaustion. When compared to their exhausted post-CABG counterpart, non-exhausted post-CABG patients had a significantly higher frequency of preoperative insulin use. Exhausted patients were significantly more likely to have higher left ventricular ejection fraction ([LVEF], OR 1.07, p=0.04), and elevated hemoglobin (OR 2.98, p=0.03) and eosinophils (OR 1.02, p=0.02) than those who were not exhausted. Conclusion Clinicians should evaluate all patients for exhaustion post-CABG surgery; patients with elevated LVEF, hemoglobin, and eosinophil levels warrant increased scrutiny. PMID:23453010

  14. Cerebral oximetry as a biomarker of postoperative delirium in cardiac surgery patients.

    PubMed

    Mailhot, Tanya; Cossette, Sylvie; Lambert, Jean; Cournoyer, Alexis; Denault, André Y

    2016-08-01

    A promising monitoring strategy for delirium is the use of cerebral oximetry, but its validity during delirium is unknown. We assessed the relationship between oximetry and delirium. We hypothesized that as cerebral oximetry values increased, delirium would resorb. An observational study was conducted with 30 consecutive adults with delirium after cardiac surgery. Oximetry, delirium assessments, and clinical data were collected for 3 consecutive days after delirium onset. Oximetry was obtained using near-infrared spectroscopy. Delirium was assessed using diagnosis, occurrence (Confusion Assessment Method-ICU), and severity scales (Delirium Index). All patients presented delirium at entry. The mean oximetry value decreased from 66.4±6.7 (mean±SD) to 50.8±6.8 on the first day after delirium onset and increased in patients whose delirium resorbed over the 3 days. The relationship between oximetry, delirium diagnosis, and severity was analyzed with a marginal model and linear mixed models. Cerebral oximetry was related to delirium diagnosis (P≤.0001) and severity (P≤.0001). This study highlighted the links between increased cerebral oximetry values and delirium resorption. Oximetry values may be useful in monitoring delirium progression, thus assisting in the management of this complicated condition. Copyright © 2016 Elsevier Inc. All rights reserved.

  15. Preoperative Cognitive Performance and Postoperative Delirium Are Independently Associated With Future Dementia in Older People Who Have Undergone Cardiac Surgery: A Longitudinal Cohort Study*

    PubMed Central

    Smulter, Nina S.; Lindahl, Elisabeth; Lindkvist, Marie; Engström, Karl Gunnar; Gustafson, Yngve G.; Olofsson, Birgitta

    2017-01-01

    Objective: To investigate if postoperative delirium was associated with the development of dementia within 5 years after cardiac surgery. Design: Longitudinal cohort study. Setting: Cardiothoracic Division, Umeå University Hospital, Sweden. Patients: Patients aged 70 years old or older (n = 114) scheduled for routine cardiac procedures with cardiopulmonary bypass without documented dementia were enrolled in 2009. Intervention: Structured assessments were performed preoperatively, 1 and 4 days after extubation, and 1, 3, and 5 years postoperatively. Measurements and Main Results: Patients were assessed comprehensively, including cognitive and physical function, coexisting medical conditions, demographic characteristics, and medications. Diagnoses of delirium, depression, and dementia were made according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criteria. During the 5-year period, 30 of 114 participants (26.3%) developed dementia. Postoperative delirium had occurred in 87% of those who later developed dementia. A multivariable logistic regression model showed a lower preoperative Mini-Mental State Examination score (p < 0.001; odds ratio, 0.68; 95% CI, 0.54–0.84) and the occurrence of postoperative delirium (p = 0.002; odds ratio, 7.57; 95% CI, 2.15–26.65) were associated with dementia occurrence. Conclusions: Our findings suggest that older patients with reduced preoperative cognitive functions or who develop postoperative delirium are at risk of developing dementia within 5 years after cardiac surgery. Cognitive functions should be screened for preoperatively, those who develop postoperative delirium should be followed up to enable early detection of dementia symptoms, and management should be implemented. PMID:28481752

  16. Perception of pediatric pain: a comparison of postoperative pain assessments between child, parent, nurse, and independent observer.

    PubMed

    Khin Hla, Thel; Hegarty, Mary; Russell, Phil; Drake-Brockman, Thomas F; Ramgolam, Anoop; von Ungern-Sternberg, Britta S

    2014-11-01

    Pain is a subjective experience. In children with limited understanding and communication skills, reliable assessment of pain is challenging. Self-reporting of pain is the gold standard of pain measurement. For children who are unable to self-report their pain, assessments made by their parents are often used as a proxy measure. The validity of this approach has not been conclusively determined. To investigate differences in the assessment of pediatric pain between children, parents, nurses, and independent observers in the acute postoperative setting. Three hundred and seven children (207 verbal, 100 nonverbal) undergoing elective day-case surgery were asked to participate in this quality of care audit. Pain scores given by verbal children, their parents, nurses, and independent observers were collected. A numerical rating scale or the Wong-Baker Faces Pain Scale was used. All participants were blinded from other scorers. For verbal children, scores reported by patients and their parents did not differ significantly. Median [inter-quartile range (IQR)] scores by children, parents, nurses, and independent observers were, respectively, 2.0 (0-4.0), 2.0 (1.0-4.0), 0.0 (0-2.0), and 1.0 (0-2.0). In nonverbal children, median (IQR) scores by parents, nurses, and independent observers were 1.0 (0-3.0), 0 (0-1.0), and 0 (0-2.0), respectively. The agreement between the different scorers was statistically significant. Children's pain self-reports should be used wherever possible to guide management, but in their absence, parental pain scores can be reliably used as a surrogate measure. Nurses and independent observers produce lower pain scores than parents or children, which may result in inadequate treatment of pain. © 2014 John Wiley & Sons Ltd.

  17. The effect of critical care nursing and organizational characteristics on pediatric cardiac surgery mortality in the United States.

    PubMed

    Hickey, Patricia A; Gauvreau, Kimberlee; Curley, Martha A Q; Connor, Jean A

    2014-10-01

    This study explored pediatric critical care nursing and organizational factors that impact in-hospital mortality for cardiac surgery patients across children's hospitals in the United States. Congenital heart disease is the most common birth defect and the no. 1 cause of death for infants with a congenital defect. Little is known about the impact of pediatric critical care nursing and organizational factors on pediatric mortality. Nursing leaders from 38 children's hospitals that contribute data to the Pediatric Health Information System data set completed an organizational assessment for years 2009 and 2010. These data were linked with patient-level data. The Risk Adjustment for Congenital Heart Surgery method was used to adjust for baseline patient differences in patients younger than 18 years. The odds of death increased as the institutional percentage of pediatric critical care unit nurses with 2 years' clinical experience or less increased. The odds of mortality were highest when the percentage of RNs with 2 years' clinical experience or less was 20% or greater. The odds of death decreased as the institutional percentage of critical care nurses with 11 years' clinical experience or more increased and for hospitals participating in national quality metric benchmarking. Clinical experience was independently associated with in-hospital mortality. These data are the 1st to link clinical nursing experience with pediatric patient outcomes. A cut point of 20% RNs or greater with 2 years' clinical experience or less was determined to significantly affect inpatient mortality. Participation in national quality metric benchmarking programs was significantly associated with improved mortality.

  18. Pediatric Cardiac Shear Wave Elastography for Quantitative Assessment of Myocardial Stiffness: A Pilot Study in Healthy Controls.

    PubMed

    Song, Pengfei; Bi, Xiaojun; Mellema, Daniel C; Manduca, Armando; Urban, Matthew W; Pellikka, Patricia A; Chen, Shigao; Greenleaf, James F

    2016-08-01

    The long-term goal of this study is to assess chemotherapy-induced cardiotoxicity for pediatric cancer patients using cardiac ultrasound shear wave (SW) elastography. This pilot study aimed to systematically investigate the feasibility of using cardiac SW elastography in children and provide myocardial stiffness control data for cancer patients. Twenty healthy volunteers (ages 5-18) were recruited. A novel cardiac SW elastography sequence with pulse-inversion harmonic imaging and time-aligned sequential tracking was developed for this study. Cardiac SW elastography produces and detects transient SWs propagating in the myocardium in late-diastole, which can be used to quantify myocardial stiffness. The parasternal long-axis (L-A) and short-axis (S-A) views of the interventricular septum (IVS) were feasible for pediatric cardiac SW elastography. The L-A and S-A views of the basal and mid IVS provided better success rates than those of the apical IVS. Success rates decreased with increased body mass index (BMI), but did not differ with age or gender. Two-dimensional SW speed measurements were 1.26, 1.22, 1.71 and 1.67 m/s for L-A base, L-A mid, S-A base and S-A mid IVS, respectively. All S-A SW speed values were significantly higher (p < 0.01) than L-A values due to myocardial anisotropy. No SW speed difference was observed for different ages and genders. This pilot study demonstrated, for the first time, the feasibility of using cardiac SW elastography to measure quantitative myocardial stiffness in children, and established control SW speed values for using SW elastography to assess chemo-induced cardiotoxicity for pediatric cancer patients. The results showed that the myocardial anisotropy needs to be accounted for when comparing SW speed from different imaging axes. Copyright © 2016 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.

  19. NASA Model of "Threat and Error" in Pediatric Cardiac Surgery: Patterns of Error Chains.

    PubMed

    Hickey, Edward; Pham-Hung, Eric; Nosikova, Yaroslavna; Halvorsen, Fredrik; Gritti, Michael; Schwartz, Steven; Caldarone, Christopher A; Van Arsdell, Glen

    2017-04-01

    We introduced the National Aeronautics and Space Association threat-and-error model to our surgical unit. All admissions are considered flights, which should pass through stepwise deescalations in risk during surgical recovery. We hypothesized that errors significantly influence risk deescalation and contribute to poor outcomes. Patient flights (524) were tracked in real time for threats, errors, and unintended states by full-time performance personnel. Expected risk deescalation was wean from mechanical support, sternal closure, extubation, intensive care unit (ICU) discharge, and discharge home. Data were accrued from clinical charts, bedside data, reporting mechanisms, and staff interviews. Infographics of flights were openly discussed weekly for consensus. In 12% (64 of 524) of flights, the child failed to deescalate sequentially through expected risk levels; unintended increments instead occurred. Failed deescalations were highly associated with errors (426; 257 flights; p < 0.0001). Consequential errors (263; 173 flights) were associated with a 29% rate of failed deescalation versus 4% in flights with no consequential error (p < 0.0001). The most dangerous errors were apical errors typically (84%) occurring in the operating room, which caused chains of propagating unintended states (n = 110): these had a 43% (47 of 110) rate of failed deescalation (versus 4%; p < 0.0001). Chains of unintended state were often (46%) amplified by additional (up to 7) errors in the ICU that would worsen clinical deviation. Overall, failed deescalations in risk were extremely closely linked to brain injury (n = 13; p < 0.0001) or death (n = 7; p < 0.0001). Deaths and brain injury after pediatric cardiac surgery almost always occur from propagating error chains that originate in the operating room and are often amplified by additional ICU errors. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  20. Different Respiratory Rates during Resuscitation in a Pediatric Animal Model of Asphyxial Cardiac Arrest.

    PubMed

    López, Jorge; Fernández, Sarah N; González, Rafael; Solana, María J; Urbano, Javier; López-Herce, Jesús

    2016-01-01

    Actual resuscitation guidelines recommend 10 respirations per minute (rpm) for advanced pediatric life support. This respiratory rate (RR) is much lower than what is physiological for children. The aim of this study is to compare changes in ventilation, oxygenation, haemodynamics and return of spontaneous circulation (ROSC) rates with three RR. An experimental model of asphyxial cardiac arrest (CA) in 46 piglets (around 9.5 kg) was performed. Resuscitation with three different RR (10, 20 and 30 rpm) was carried out. Haemodynamics and gasometrical data were obtained at 3, 9, 18 and 24 minutes after beginning of resuscitation. Measurements were compared between the three groups. No statistical differences were found in ROSC rate between the three RR (37.5%, 46.6% and 60% in the 10, 20 and 30 rpm group respectively P = 0.51). 20 and 30 rpm groups had lower PaCO2 values than 10 rpm group at 3 minutes (58 and 55 mmHg vs 75 mmHg P = 0.08). 30 rpm group had higher PaO2 (61 mmHg) at 3 minutes than 20 and 10 rpm groups (53 and 45 mmHg P = 0.05). No significant differences were found in haemodynamics or tissue perfusion between hyperventilated (PaCO2 <30 mmHg), normoventilated (30-50 mmHg) and hypoventilated (>50 mmHg) animals. PaO2 was significantly higher in hyperventilated (PaO2 153 mmHg) than in normoventilated (79 mmHg) and hypoventilated (47 mmHg) piglets (P<0.001). Our study confirms the hypothesis that