Interfacility Transport Shock Index Is Associated With Decreased Survival in Children.

BACKGROUND: Shock index, the ratio of heart rate to systolic blood pressure that changes with age, is associated with mortality in adults after trauma and in children with sepsis. We assessed the utility of shock index to predict sepsis diagnosis and survival in children requiring interfacility transport to a tertiary care center. METHODS: We studied children aged 1 month to 21 years who had at least 2 sets of vital signs recorded during interfacility transport to the Children's Hospital of Pittsburgh by our critical care transport team. Subjects were divided into 4 age groups: group 1 (<1 year), group 2 (1-3 years), group 3 (4-11 years), and group 4 (≥12 years). Children were also grouped into sepsis or nonsepsis group based on the International Classification of Diseases, Ninth Revision categories. Primary outcome was survival to hospital discharge. RESULTS: Of 3519 children studied, 493 (14%) had sepsis. Initial shock index decreased with increasing age: group 1, 1.45 ± 0.42 (mean ± SD); group 2, 1.35 ± 0.32; group 3, 1.20 ± 0.34; and group 4, 1.00 ± 0.32 (P < 0.001). Initial shock index was increased in children with sepsis versus those with no sepsis overall and in all age groups (all P < 0.05). Initial shock index showed a trend for association with survival in univariate analysis (P = 0.05) but was not associated with survival in a multivariable logistic regression. Highest quartile of shock index was associated with need for intensive care unit admission posttransport. CONCLUSIONS: Increased shock index in children requiring intrafacility transport was associated with hospital discharge diagnosis of sepsis but not hospital survival.

Evaluating one day versus two days preoperative lymphoscintigraphy protocols for sentinel lymph node biopsy in breast cancer.

Sentinel lymph node biopsy (SLNB) is used to detect axillary lymph node metastases in breast cancer. Preoperative radiocolloid injection with lymphoscintigraphy (PL) is performed before SLNB. Few comparisons between 1- and 2-day PL protocols exist. Opponents of a 2-day protocol have expressed concerns of radiotracer washout to nonsentinel nodes. Proponents cite lack of scheduling conflicts between PL and surgery. A total of 387 consecutive patients with clinically node-negative breast cancer underwent SLNB with PL. Lymphoscintigraphy images were obtained within 30 minutes of radiocolloid injection. Axillary lymph node dissection was performed if the sentinel lymph node (SLN) could not be identified. Data were collected regarding PL technique and results. In all, 212 patients were included in the 2-day PL group and 175 patients in the 1-day PL group. Lymphoscintigraphy identified an axillary sentinel node in 143/212 (67.5%) of patients in the 2-day group and 127/175 (72.5%) in the 1-day group (P = 0.28). SLN was identified at surgery in 209/212 (98.6%) patients in the 2-day group and 174/175 (99.4%) in the 1-day group (P = 0.41). An average of 3 SLN was found at surgery in the 2-day group compared with 3.15 in the 1-day group (P = 0.43). SLN was positive for metastatic disease in 54/212 (25.5%) patients in the 2-day group compared with 40/175 (22.9%) in the 1-day group (P = 0.55). A 2-day lymphoscintigraphy protocol allows reliable detection of the SLN, of positive SLN and equivalent SLN harvest compared with a 1-day protocol. The timing of radiocolloid injection before SLNB can be left at the discretion of the surgeon.

PA10†What i need you to know. building a collaborative communication tool.

BACKGROUND: During strategy consultation in Northern Ireland an "End of Life Care Passport" was suggested as a way to address myriad communication difficulties involved in living with evolving illness. AIM: To build a patient-owned communication tool to facilitate important conversations and capture key information as health changes. METHODS: Participatory action methods used to engage service users, carers, patient advocates, and healthcare professionals. Views harnessed via: face to face, email, telephone, via series of workshops. Iterative process of drafting, dissemination, evaluation, re drafting. Pilot version launched (350 disseminated): used for a 3 month evaluative period by 3 groups: living with dementia, with motor neurone disease, with advanced respiratory illness. Feedback widely sought from participating individuals and groups. RESULTS: The emergent tool(1) very different from originally envisaged. Key issues include widespread rejection of "End of Life Care Passport" (felt to be professionally based perspective); very high level of engagement with the process, imperative to develop a tool which focusses on language and communication needs of patient and carers rather than professionals. Emergent tool contains ten sections and brief explanatory content. Housed as A5 portable ring binder (e-version suggested), updated collaboratively by patient, carers, key supporters, professionals. CONCLUSION: Patients and carers face multiple communication difficulties negotiating changing health. At particular risk are those with rare illness and those whose capacity is limited due to illness, language or cultural barriers. There is a role for a communication tool which houses key evolving information, is completed collaboratively and patient owned and controlled. REFERENCE: http://www.rcgp.org.uk/rcgp-near-you/rcgp-northern-ireland/my-healthcare-passport.aspx.

Diastolic hypotension is an unrecognized risk factor for ß-agonist-associated myocardial injury in children with asthma.

OBJECTIVES: Tachycardia and diastolic hypotension have been associated with ß-2 agonist use. In the setting of ß-agonist-induced chronotropy and inotropy, diastolic hypotension may limit myocardial blood flow. We hypothesized that diastolic hypotension is associated with ß-agonist use and that diastolic hypotension and tachycardia are associated with biochemical evidence of myocardial injury in children with asthma. DESIGN: Two patient cohorts were collected. The first, consisting of patients transported for respiratory distress having received at least 10 mg of albuterol, was studied for development of tachycardia and hypotension. The second, consisting of patients who had troponin measured during treatment for status asthmaticus with continuous albuterol, was studied for factors associated with elevated troponin. Exclusion criteria for both cohorts included age younger than 2 years old, sepsis, pneumothorax, cardiac disease, and antihypertensive use. Albuterol dose, other medications, and vital signs were collected. Diastolic and systolic hypotension were defined as an average value below the fifth percentile for age and tachycardia as average heart rate above the 98th percentile for age. PATIENTS: Ninety of 1,390 children transported for respiratory distress and 64 of 767 children with status asthmaticus met inclusion criteria. MEASUREMENTS AND MAIN RESULTS: Diastolic hypotension occurred in 56% and 98% of the first and second cohorts, respectively; tachycardia occurred in 94% and 95% of the first and second cohorts, respectively. Diastolic hypotension and tachycardia had a weak linear correlation with albuterol dose (p = 0.02 and p = 0.005, respectively). Thirty-six percent had troponin > 0.1 ng/mL (range, 0-12.6). In multivariate analysis, interaction between diastolic hypotension and tachycardia alone was associated with elevated troponin (p = 0.02). CONCLUSIONS: Diastolic hypotension and tachycardia are dose-dependent side effects of high-dose albuterol. In high-risk patients with status asthmaticus treated with albuterol, diastolic hypotension and tachycardia are associated with biochemical evidence of myocardial injury. Diastolic hypotension, especially combined with tachycardia, could be a reversible risk factor for myocardial injury related to ß-agonist use.

Plasma exchange in a 13-year-old male with acute intravascular hemolysis and acute kidney injury after placement of a ventricular assist device.

Intravascular hemolysis and resulting plasma-free hemoglobin elevation has been associated with acute kidney injury via several mechanisms. Proximal tubular injury due to iron compound deposition and nitric oxide sequestration with subsequent impairment of the microcirculation and hypoperfusion are specific adverse effects of intravascular hemolysis that may contribute to acute kidney injury. Therefore, removal of plasma-free hemoglobin and restoration of normal nitric oxide vasodilatory mechanisms may play a beneficial role in treating acute kidney injury secondary to acute intravascular hemolysis. We report herein the case of a 13-year-old patient with severe intravascular hemolysis and acute kidney injury and describe the role of plasma exchange with plasma replacement in his successful recovery.

Critical congenital heart disease--utility of routine screening for chromosomal and other extracardiac malformations.

Objective. Infants with critical congenital heart disease (CHD) can have genetic and other extracardiac malformations, which add to the short- and long-term risk of morbidity and perhaps mortality. We sought to examine our center's practice of screening for extracardiac anomalies and to determine the yield of these tests among specific cardiac diagnostic categories. Design. Retrospective review of infants admitted to the cardiac intensive care unit with a new diagnosis of CHD. Subjects were categorized into six groups: septal defects (SD), conotruncal defects (CTD), single-ventricle physiology (SV), left-sided obstructive lesions (LSO), right-sided obstructive lesions (RSO), and "other" (anomalous pulmonary venous return, Ebstein's anomaly). Screening modalities included genetic testing (karyotype and fluorescent in situ hybridization for 22q11.2 deletion), renal ultrasound (RUS), and head ultrasound (HUS). Results. One hundred forty-one patients were identified. The incidence of cardiac anomalies was: CTD (36%), SD (18%), SV (18%), LSO (14%), RSO (3%), and "other" (8%). Overall 14% had an abnormal karyotype, 5% had a deletion for 22q11.2, 28% had an abnormal RUS and 22% had abnormal HUS. Patients in SD and SV had the highest incidence of abnormal karyotype (36% and 17%); 22q11.2 deletion was present only in CTD and LSO groups (9% and 7%, respectively); abnormal RUS and HUS were seen relatively uniformly in all categories. Premature infants had significantly higher incidence of renal 43% vs. 24%, and intracranial abnormalities 46% vs. 16%. Conclusion. Infants with critical CHD and particularly premature infants have high incidence of genetic and other extracardiac anomalies. Universal screening for these abnormalities with ultrasonographic and genetic testing maybe warranted because early detection could impact short and long-term outcomes.

Discontinuation of prolonged infusions of dexmedetomidine in critically ill children with heart disease.

PURPOSE: To describe changes in hemodynamic variables, sedation, and pain score after discontinuation of prolonged infusions of dexmedetomidine in a pediatric population of critically ill cardiac patients. METHODS: Retrospective case series of patients who received continuous infusions of dexmedetomidine for longer than 3 days in a pediatric cardiac intensive care unit from 2008 to 2010. RESULTS: Sixty-two patients, age 5.2 months (range 0.3 months-17 years) and weight 5.1 kg (range 2.2-84 kg), were included. Thirty-nine patients (63%) were younger than 1 year of age. Median duration of dexmedetomidine infusion was 5.8 days (range 4-26 days) and median infusion dose was 0.71 µg/kg/h (range 0.2-2.1 µg/kg/h). Median weaning time and dose at discontinuation were 43 h (range 0-189 h) and 0.2 µg/kg/h (range 0.1-1.3 µg/kg/h). Tachycardia, transient hypertension and agitation were observed in 27, 35 and 27% of patients. Episodes of tachycardia were more frequent in children older than 1 year of age (61 vs. 8%, p < 0.001), patients who received dexmedetomidine for 4 days when compared to those who received 5 days or longer (48 vs. 17%, p = 0.011), and patients whose infusion was discontinued abruptly (42 vs. 14%, p = 0.045). Tachyarrhythmias were seen in nine patients (15%) after discontinuation of the dexmedetomidine infusion. Adequate sedation and analgesia scores at the moment of infusion discontinuation were seen in 90 and 88% of patients, respectively. CONCLUSIONS: Our study suggests that tachycardia, transient hypertension, and agitation are frequently observed in pediatric cardiac intensive care unit patients after discontinuing prolonged dexmedetomidine infusions.

Preoperative management in patients with single-ventricle physiology.

OBJECTIVE: Advancements in the preoperative management of patients with single-ventricle physiology continue to evolve. Previous reports have questioned the benefit of using inhaled nitrogen in single-ventricle patients, suggesting that this therapeutic modality may not provide adequate systemic cardiac output. The objective of this study was to review our institutional experience managing preoperative patients with single-ventricle physiology using a combination of afterload reduction and inhaled hypoxemic therapy. DESIGN, SETTING, AND PATIENTS: This is a retrospective review of 49 consecutive single-ventricle patients admitted preoperatively between July 2004 and January 2009, to the cardiac intensive care unit at Children's Hospital of Pittsburgh who underwent single-ventricle palliation, and treated preoperatively with milrinone and inhaled nitrogen. Therapeutic interventions and indirect indicators of cardiac output were collected on day of admission (time 0) and compared with those collected on the morning of surgery (time 1); data included clinical assessment, hemodynamic measurements, and laboratory values. RESULTS: When comparing time 0 to time 1, there was a statistically significant decrease in lactate (from 2.2 to 1.8 mEq/L [P < 0.001]) and an increase in pH (from 7.36 to 7.41 [P < 0.001]), serum bicarbonate (from 24.16 to 27.55 mmol/L [P < 0.001]) and arterial PaO2 (from 38.10 to 41.82 mm Hg [P = 0.027]). Preoperatively, there were no deaths, and only two patients had an evidence of multiorgan dysfunction on day of surgery (time 1). CONCLUSION: Our results suggest that a combination of afterload reduction and hypoxemic therapy was able to maintain an appropriate distribution of the cardiac output in the majority of preoperative patients with single-ventricle physiology. An adequate balance of systemic and pulmonary blood flow was successfully achieved with an increase in arterial PaO2 values.

Perioperative use of dexmedetomidine is associated with decreased incidence of ventricular and supraventricular tachyarrhythmias after congenital cardiac operations.

BACKGROUND: Postoperative tachyarrhythmias remain a common complication after congenital cardiac operations. Dexmedetomidine (DEX), an α-2 adrenoreceptor agonist, can have a therapeutic role in supraventricular tachyarrhythmias for cardioversion to sinus rhythm or heart rate control. Whether routine perioperative use of DEX decreases the incidence of supraventricular and ventricular tachyarrhythmias was studied. METHODS: In this prospective cohort study, 32 pediatric patients undergoing cardiothoracic operations received DEX and were compared with 20 control patients who did not receive DEX. RESULTS: Dexmedetomidine was started after anesthesia induction and continued intraoperatively and postoperatively for 38±4 hours (mean dose, 0.76±0.04 µg/kg/h). Ten control patients and 2 DEX patients sustained 16 episodes of tachyarrhythmias (p=0.001), including a 25% vs 0% (p=0.01) incidence of ventricular tachycardia and 25% vs 6% (p=0.05) of supraventricular arrhythmias in the control and DEX group, respectively. Transient complete heart block occurred in 2 control patients and in 1 DEX patient. Control patients had a higher heart rate (141±5 vs 127±3 beats/min, p=0.03), more sinus tachycardia episodes (40% vs 6%; p=0.008), required more antihypertensive drugs with nitroprusside (20±7 vs 4±1 µg/kg; p=0.004) and nicardipine (13±5 vs 2±1 µg/kg; p=0.02), and required more fentanyl (39±8 vs 19±3 µg/kg; p=0.005). CONCLUSIONS: Perioperative use of dexmedetomidine is associated with a significantly decreased incidence of ventricular and supraventricular tachyarrhythmias, without significant adverse effects.

Updated American College of Critical Care Medicine--pediatric advanced life support guidelines for management of pediatric and neonatal septic shock: relevance to the emergency care clinician.

Shock is a major preventable cause of morbidity and mortality in children referred to emergency care. The recently updated American College of Critical Care Medicine guidelines for the management of newborns and children with septic shock emphasize the role of emergency care in improving survival and functional outcomes. Implementation of these guidelines of stepwise use of fluids, antibiotics, and, if necessary, inotropes within the first hour of admission to the emergency department can reduce mortality and neurological morbidity risks 2-fold. Therapies should be goal directed to maintain age-specific threshold heart rates and blood pressure as well as a capillary refill of less than 3 seconds or 2 seconds or less. Inotropes should be delivered through peripheral intravenous or intraosseous access when central access is unavailable because delay in inotrope delivery can greatly increase mortality risks. Emergency care systems should be organized to facilitate recognition, triage, and treatment of shock in the first hour. Emergency departments should be stocked with ready access to antibiotics, fluids, and inotrope infusions, and clinicians should be trained in the delivery of goal-directed fluid, antibiotics, and inotrope therapies in the first hour of resuscitation. For newborns, in addition to fluids, antibiotics, and inotropes, a prostaglandin infusion should be available within 10 minutes if duct-dependent congenital heart disease is a possibility.

Molecular detection of micrometastatic breast cancer in histopathology-negative axillary lymph nodes fails to predict breast cancer recurrence: a final analysis of a prospective multi-institutional cohort study.

BACKGROUND: To address the clinical relevance of molecular detection of occult breast cancer in sentinel lymph nodes and nonsentinel axillary lymph nodes (ALN), we initiated the Minimally Invasive Molecular Staging of Breast Cancer (MIMS) trial, a multi-institutional prospective cohort study. This trial represents the first prospective cohort study in which a multimarker, real-time reverse transcription polymerase chain reaction (RT-PCR) analysis was applied to the detection of breast cancer micrometastases in ALN. MATERIALS AND METHODS: Sentinel and/or nonsentinel ALN from 501 breast cancer subjects with T1-T3 primary tumors were analyzed by standard histopathology and multimarker, real-time RT-PCR analysis. Seven breast cancer-associated genes (mam, mamB, PIP, CK19, muc1, PSE, and CEA) known to be overexpressed in metastatic breast cancer compared with control lymph nodes were used. Follow-up data were collected for 5 years. RESULTS: Of the 501 breast cancer subjects enrolled, 348 were node negative and completed the 5-year follow-up. Of these patients (n = 94), 27% demonstrated evidence of molecular overexpression. The 5-year relapse-free survival rate was 95.4% (95% confidence interval [95% CI], 92.4-97.2%). No single gene or combination of study genes was predictive of recurrence. CONCLUSIONS: The genes in this study panel failed to be predictive of clinical relapse. This may be a function of several factors: the low event rate at 5 years, the particular gene set, the methodology used for detection/analysis or that our original hypothesis was wrong and that the presence of positive marker signal by real-time RT-PCR is not associated with a worsened clinical outcome.

Outcomes in pancreatic cancer surgery.

The increase in surgery for pancreatic cancer during the last 3 decades can be correlated with a gradual decline in operative mortality and postoperative complications. Although not all surgeons (nor all hospitals) can have equal outcomes, the definition and tabulation of these outcomes have been difficult. This article asks several pertinent questions: (1) what is the scientific rationale for pancreatic resection? (2) what are the best available results at this time? (3) who should be performing pancreatic resections? The article analyzes results of resection for adenocarcinoma of the exocrine pancreas, and excludes duodenal and ampullary cancers, pancreatic endocrine tumors, and tumors of less malignant potential.

Electrocardiographic effects of dexmedetomidine in patients with congenital heart disease.

OBJECTIVE: Assessment of electrocardiographic (ECG) effects of dexmedetomidine. DESIGN: Prospective observational study including children 0-17 years of age with congenital heart disease (CHD) and children following cardiothoracic surgery. Patients who did not receive dexmedetomidine were used as a control group. All patients had two ECGs: one baseline, pre-dexmedetomidine (T1) and one during dexmedetomidine infusion (T2). MEASUREMENTS AND RESULTS: Fifty-one patients, median age of 0.5 years (IQR = 3.4), and 25 patients, age 0.25 (IQR = 2.9), were included in the dexmedetomidine and control groups, respectively. Forty received a dexmedetomidine-loading dose of 1 microg/kg (IQR = 0.5). At T2, the dexmedetomidine infusion was 1 microg/kg/h (IQR = 0.5). In the dexmedetomidine group, heart rate (HR) decreased from 140 +/- 22 to 115 +/- 23 (P < 0.001); PR, PRc and PR index changed from 115 +/- 28 to 122 +/- 29 ms (P = 0.01), 174 +/- 38 to 167 +/- 35 ms (P = 0.07) and 15,882 +/- 3,565 to 13,792 +/- 3,311 (P < 0.001), respectively. QRS decreased from 84 +/- 21 to 80 +/- 21 ms (P = 0.02), and QTc had no change (433 +/- 47 to 435 +/- 36 ms). When compared to the control group, none of the ECG intervals had any difference other than a trend towards lower HR (P = 0.08). Neonates and infants had a bigger drop in the HR compared to older children (P < 0.001), while other parameters were similar. At T2 none of the dexmedetomidine group patients had atrioventricular block or other arrhythmia. Four patients in the control group had accelerated junctional rhythm. CONCLUSIONS: Use of dexmedetomidine in patients with CHD and patients following cardiothoracic surgery is not associated with any significant ECG interval abnormalities other than a trend towards lower HR.

Do neonates, infants and young children need a higher dose of enoxaparin in the cardiac intensive care unit?

BACKGROUND: Thromboembolic events are a serious complication occurring in critically ill children admitted to the cardiac intensive care unit. Although enoxaparin is one of the current anticoagulants of choice, dosages in children are extrapolated from adult guidelines. Recent data suggest that this population may need a higher dose than what is currently recommended to achieve target anti-factor Xa levels. The purpose of this study was to evaluate whether children less than 2 years old admitted to the cardiac intensive care unit require a higher enoxaparin dose than that currently recommended to achieve target anti-factor Xa levels. METHODS: Retrospective chart review including patients who received enoxaparin for the treatment or prophylaxis of venous thrombosis between January, 2005 and October, 2007. Patients were classified as younger and older as well as prophylactic and therapeutic on the basis of age and enoxaparin dose, respectively. Younger patients were those 2 month old or less and older patients were those older than 2 months of age. RESULTS: A total of 31 patients were identified; 13 (42%) were 2 months or younger and 25 (81%) were postoperative patients. Ten (32%) received prophylactic and 21 (68%) received therapeutic enoxaparin doses. To achieve optimal anti-factor Xa levels, enoxaparin dose was increased in all groups and reached statistical significance in all patients except those older than 2 months who received prophylactic enoxaparin. An average of 2.8 dosage adjustments was needed. No bleeding complications were reported. CONCLUSIONS: Young children, infants, and neonates admitted to the cardiac intensive care unit required a significantly higher enoxaparin dose than that currently recommended to achieve target anti-factor Xa levels.