Spillover of Early Extubation Practices From the Pediatric Heart Network Collaborative Learning Study.

OBJECTIVES: The Pediatric Heart Network Collaborative Learning Study used collaborative learning strategies to implement a clinical practice guideline that increased rates of early extubation after infant repair of tetralogy of Fallot and coarctation of the aorta. We assessed early extubation rates for infants undergoing cardiac surgeries not targeted by the clinical practice guideline to determine whether changes in extubation practices spilled over to care of other infants. DESIGN: Observational analyses of site's local Society of Thoracic Surgeons Congenital Heart Surgery Database and Pediatric Cardiac Critical Care Consortium Registry. SETTING: Four Pediatric Heart Network Collaborative Learning Study active-site hospitals. PATIENTS: Infants undergoing ventricular septal defect repair, atrioventricular septal defect repair, or superior cavopulmonary anastomosis (lower complexity), and arterial switch operation or isolated aortopulmonary shunt (higher complexity). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Aggregate outcomes were compared between the 12 month pre-clinical practice guideline and 12 months after study completion (Follow Up). In infants undergoing lower complexity surgeries, early extubation increased during Follow Up compared with Pre-Clinical Practice Guideline (30.2% vs 18.8%, p = 0.006), and hours to initial postoperative extubation decreased. We observed variation in these outcomes by surgery type, with only ventricular septal defect repair associated with a significant increase in early extubation during Follow Up compared with Pre-Clinical Practice Guideline (47% vs 26%, p = 0.006). Variation by study site was also seen, with only one hospital showing an increase in early extubation. In patients undergoing higher complexity surgeries, there was no difference in early extubation or hours to initial extubation between the study eras. CONCLUSIONS: We observed spillover of extubation practices promoted by the Collaborative Learning Study clinical practice guideline to lower complexity operations not included in the original study that was sustainable 1 year after study completion, though this effect differed across sites and operation subtypes. No changes in postoperative extubation outcomes following higher complexity surgeries were seen. The significant variation in outcomes by site suggests that center-specific factors may have influenced spillover of clinical practice guideline practices.

The final reason paediatric Cardiac ICU patients require care prior to discharge to the floor: a single-centre survey.

OBJECTIVE: To determine the Final ICU Need in the 24 hours prior to ICU discharge for children with cardiac disease by utilising a single-centre survey. METHODS: A cross-sectional survey was utilised to determine Final ICU Need, which was categorised as "Cardiovascular", "Respiratory", "Feeding", "Sedation", "Systems Issue", or "Other" for each encounter. Survey responses were obtained from attending physicians who discharged children (≤18 years of age with ICU length of stay >24 hours) from the Cardiac ICU between April 2016 and July 2018. MEASUREMENTS AND RESULTS: Survey response rate was 99% (n = 1073), with 667 encounters eligible for analysis. "Cardiovascular" (61%) and "Respiratory" (26%) were the most frequently chosen Final ICU Needs. From a multivariable mixed effects logistic regression model fitted to "Cardiovascular" and "Respiratory", operations with significantly reduced odds of having "Cardiovascular" Final ICU Need included Glenn palliation (p = 0.003), total anomalous pulmonary venous connection repair (p = 0.024), truncus arteriosus repair (p = 0.044), and vascular ring repair (p < 0.001). Short lengths of stay (<7.9 days) had significantly higher odds of "Cardiovascular" Final ICU Need (p < 0.001). "Cardiovascular" and "Respiratory" Final ICU Needs were also associated with provider and ICU discharge season. CONCLUSIONS: Final ICU Need is a novel metric to identify variations in Cardiac ICU utilisation and clinical trajectories. Final ICU Need was significantly influenced by benchmark operation, length of stay, provider, and season. Future applications of Final ICU Need include targeting quality and research initiatives, calibrating provider and family expectations, and identifying provider-level variability in care processes and mental models.

A Collaborative Learning Assessment of Developmental Care Practices for Infants in the Cardiac Intensive Care Unit.

OBJECTIVE: Assess differences in approaches to and provision of developmental care for infants undergoing surgery for congenital heart disease. STUDY DESIGN: A collaborative learning approach was used to stratify, assess, and compare individualized developmental care practices among multidisciplinary teams at 6 pediatric heart centers. Round robin site visits were completed with structured site visit goals and postvisit reporting. Practices of the hosting site were assessed by the visiting team and reviewed along with center self-assessments across specific domains including pain management, environment, cue-based care, and family based care coordination. RESULTS: Developmental care for infants in the cardiac intensive care unit (CICU) varies at both a center and individual level. Differences in care are primarily driven by variations in infrastructure and resources, composition of multidisciplinary teams, education of team members, and use of developmental care champions. Management of pain follows a protocol in most cardiac intensive care units, but the environment varies across centers, and the provision of cue-based infant care and family-based care coordination varies widely both within and across centers. The project led to proposed changes in clinical care and center infrastructure at each participating site. CONCLUSIONS: A collaborative learning design fostered rapid dissemination, comparison, and sharing of strategies to approach a complex multidisciplinary care paradigm. Our assessment of experiences revealed marked variability across and within centers. The collaborative findings were a first step toward strategies to quantify and measure developmental care practices in the cardiac intensive care unit to assess the association of complex inpatient practices with long-term neurodevelopmental outcomes.

Changes in Anesthetic and Postoperative Sedation-Analgesia Practice Associated With Early Extubation Following Infant Cardiac Surgery: Experience From the Pediatric Heart Network Collaborative Learning Study.

OBJECTIVES: The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation. DESIGN: Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation. SETTING: Five children's hospitals. PATIENTS: A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation. CONCLUSIONS: The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.

Platelet Inhibition in Shunted Infants on Aspirin at Short and Midterm Follow-Up.

There are few data to guide aspirin therapy to prevent shunt thrombosis in infants. We aimed to determine if aspirin administered at conventional dosing in shunted infants resulted in ≥50% arachidonic acid (AA) inhibition in short and midterm follow-up using thromboelastography with platelet mapping (TEG-PM) and to describe bleeding and thrombotic events during follow-up. We performed a prospective observational study of infants on aspirin following Norwood procedure, aortopulmonary shunt alone, or cavopulmonary shunt surgery. We obtained TEG-PM preoperatively, after the third dose of aspirin, at the first postoperative clinic visit, and 2-8 months after surgery. The primary outcome was the proportion of subjects with ≥50% AA inhibition on aspirin. All bleeding and thrombotic events were collected. Of 24 infants analyzed, 13% had ≥50% AA inhibition at all designated time points after aspirin initiation; 38% had ≥50% AA inhibition after the third aspirin dose of aspirin, 60% at the first postoperative clinic visit, and 26% 2-8 months after surgery. Bleeding events occurred in eight subjects, and two had a thrombotic event. Bleeding events were associated with greater AA inhibition just prior to starting aspirin (p = 0.02) and after the third dose of aspirin (p = 0.04), and greater ADP inhibition before surgery (p = 0.03). The majority of infants failed to consistently have ≥50% AA inhibition when checked longitudinally postoperatively. Preoperative TEG-PM may be useful in identifying infants at higher risk of bleeding events on aspirin in the early postoperative period. Further research is needed to guide antiplatelet therapy in this population.

Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery.

OBJECTIVE: To determine whether a collaborative learning strategy-derived clinical practice guideline can reduce the duration of endotracheal intubation following infant heart surgery. DESIGN: Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre- and post-clinical practice guideline implementation at the four sites participating in the collaborative (active sites) compared with data from five Pediatric Heart Network centers not participating in collaborative learning (control sites). SETTING: Ten children's hospitals. PATIENTS: Data were collected for infants following two-index operations: 1) repair of isolated coarctation of the aorta (birth to 365 d) and 2) repair of tetralogy of Fallot (29-365 d). There were 240 subjects eligible for the clinical practice guideline at active sites and 259 subjects at control sites. INTERVENTIONS: Development and application of early extubation clinical practice guideline. MEASUREMENTS AND MAIN RESULTS: After clinical practice guideline implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p < 0.001) with no increase in reintubation rate. The median duration of postoperative intubation among active sites decreased from 21.2 to 4.5 hours (p < 0.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p = 0.63). At active sites, clinical practice guideline implementation had no statistically significant impact on median ICU length of stay (71.9 hr pre- vs 69.2 hr postimplementation; p = 0.29) for the entire cohort. There was a trend toward shorter ICU length of stay in the tetralogy of Fallot subgroup (71.6 hr pre- vs 54.2 hr postimplementation, p = 0.068). CONCLUSIONS: A collaborative learning strategy designed clinical practice guideline significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation clinical practice guideline did not significantly change postoperative ICU length of stay.

Rationale and methodology of a collaborative learning project in congenital cardiac care.

BACKGROUND: Collaborative learning is a technique through which individuals or teams learn together by capitalizing on one another's knowledge, skills, resources, experience, and ideas. Clinicians providing congenital cardiac care may benefit from collaborative learning given the complexity of the patient population and team approach to patient care. RATIONALE AND DEVELOPMENT: Industrial system engineers first performed broad-based time-motion and process analyses of congenital cardiac care programs at 5 Pediatric Heart Network core centers. Rotating multidisciplinary team site visits to each center were completed to facilitate deep learning and information exchange. Through monthly conference calls and an in-person meeting, we determined that duration of mechanical ventilation following infant cardiac surgery was one key variation that could impact a number of clinical outcomes. This was underscored by one participating center's practice of early extubation in the majority of its patients. A consensus clinical practice guideline using collaborative learning was developed and implemented by multidisciplinary teams from the same 5 centers. The 1-year prospective initiative was completed in May 2015, and data analysis is under way. CONCLUSION: Collaborative learning that uses multidisciplinary team site visits and information sharing allows for rapid structured fact-finding and dissemination of expertise among institutions. System modeling and machine learning approaches objectively identify and prioritize focused areas for guideline development. The collaborative learning framework can potentially be applied to other components of congenital cardiac care and provide a complement to randomized clinical trials as a method to rapidly inform and improve the care of children with congenital heart disease.

Reducing blood testing in pediatric patients after heart surgery: a quality improvement project.

OBJECTIVES: To safely optimize blood testing and costs for pediatric cardiac surgical patients without adversely impacting patient outcomes. DESIGN: This is a quality improvement cohort project with pre- and postintervention groups. SETTING: University-affiliated pediatric cardiac ICU in a tertiary care children's hospital. PATIENTS: All patients were surgical patients for whom Risk Adjustment for Congenital Heart Surgery categories allowed for stratification by complexity. The preintervention group was treated in 2010 and the postintervention group in 2011. INTERVENTIONS: Laboratory ordering processes were analyzed, and practice changed to limit standing blood test orders and requires individualized ordering. MEASUREMENTS AND MAIN RESULTS: Three hundred nineteen patients were studied in 2010 and 345 in 2011. Groups were similar in median age, weight, length of stay (ICU length of stay), and Risk Adjustment for Congenital Heart Surgery category. There was a reduction in the total blood tests per patient (24 vs 38; p < 0.0001) and length of stay adjusted tests per patient-day (10.4 vs 14.4; p = 0.0001) in the postintervention group. The largest test reductions were blood gases and single electrolytes. Adverse outcomes, such as extubation failure (6.4% vs 5.6%), central catheter-associated bloodstream infection (2.2 vs 1.5), and hospital mortality (0.6% vs 0.6%), were not significantly different between the groups. Cost analysis demonstrated an overall laboratory cost savings of 32%. In addition, the volume of packed RBC transfusions was also significantly decreased in the postintervention group among the most complex patients (Risk Adjustment for Congenital Heart Surgery, 6). CONCLUSIONS: Blood testing rates were safely decreased in postoperative pediatric cardiac patients by changing laboratory ordering practices. In addition, packed RBC transfusion was decreased among the most complex patients.

The impact of human rhinovirus infection in pediatric patients undergoing heart surgery.

Human rhinovirus (HRV), the most common cause of upper respiratory infection in children, can present as bronchiolitis, pneumonia, or asthma exacerbations. The impact of HRV in infants and toddlers with congenital heart disease is poorly defined. A case-control study was performed to compare the clinical course for 19 young children with respiratory symptoms who tested positive for rhinovirus after heart surgery with that of 56 matched control subjects. The control subjects were matched by surgical repair, age, weight, and time of the year. Patients with known HRVs before surgery and control subjects with respiratory symptoms or positive test results for viruses were excluded from the study. Human rhinovirus infection was associated with more than a tenfold increase in the odds of noninvasive ventilation after extubation (odds ratio [OR] 11.45; 95 % confidence interval [CI] 3.97-38.67), a 12-fold increase in the probability of extubation failure (OR 12.84; 95 % CI 2.93-56.29), and increased use of pulmonary medications including bronchodilator and nitric oxide (p < 0.001). As a result, the hospital length of stay (HLOS) was two times longer than for the control subjects (p < 0.001), and the cardiac intensive care unit (CICU) length of stay (CICU LOS) was three times longer (p < 0.0001). The intubation time was significantly longer (p < 0.001), and the CICU respiratory charges were significantly greater (p = 0.001) for the infected patients. Human rhinovirus increases resource use and prolongs postoperative recovery after pediatric heart surgery. Surgery timing should be delayed for patients with rhinovirus if possible.

Transthoracic echocardiographic predictors of left atrial hypertension in patients on venoarterial extracorporeal membrane oxygenation.

Decompression of the left heart in patients supported with extracorporeal membrane oxygenation (ECMO) is often warranted to protect the myocardium and facilitate recovery. We studied the ability of standard echocardiographic parameters to predict left atrial hypertension by reviewing 3 cardiac patients supported with ECMO who subsequently underwent left atrial decompression. We found that standard echocardiographic parameters poorly predict the need for left atrial decompression on ECMO. Following a more specific diagnostic algorithm to estimate left-sided filling pressure in patients with depressed ejection fraction may significantly improve the ability of echocardiography to accurately predict left atrial hypertension and the need for decompression.

Heterotaxy syndrome: impact of ventricular morphology on resource utilization.

Patients with heterotaxy syndrome (HS) have significant cardiac and extracardiac anomalies that impact outcome. To improve the management of this complex patient population, we performed a comprehensive analysis of their anatomic and clinical features along with an evaluation of resource utilization data. The objectives were to describe anatomic and clinical features of patients with HS syndrome treated at a single center from 1992 to 2011 focusing on the impact of ventricular morphology (univentricular [UV] vs. biventricular [BV]) on clinical outcomes and resource utilization. Clinical and echocardiographic data from patients with HS were abstracted from medical records. Health care costs were indexed to inflation. Seventy-eight patients were identified with HS ranging in age from 1 day to 29 years old. UV morphology was present in 46 patients (59 %), most commonly with right-ventricular dominance (36 of 46). The presence of extra cardiac anomalies did not differ between the UV and BV groups (82 vs. 78 %) nor did morbidities, such as need for enteral tube feedings (47 vs. 25 %) or pacemaker placement (24 vs. 25 %). Mortality was 28 % in the entire cohort: 39 % in univentricuar patients versus 10.5 % in those with biventricular anatomy. Hospital length of stay for medical illnesses was similar in both groups, but length of stay after surgery was significantly longer in UV than BV patients. Among survivors, UV patients had greater median hospital costs (TeX 67,732, p < 0.001), but when this was adjusted for mortality and variable follow-up, there were no differences in health care costs within the first year of life. Significant health care dollars are used to manage children with HS, the majority of which involve expenses related to surgical care. Although patients with biventricular morphology have better survival, morbidity and resource utilization are similar to those for UV patients especially within the first year of life.

Simple versus complex truncus arteriosus: neutralization of risk but with increased resource utilization.

This study examined simple versus complex forms of truncus arteriosus (TA) results in the current era with regard to mortality, reintervention, and resource utilization. From 1999 to 2008, 42 infants underwent primary repair of TA, including 22 simple forms of TA without associated anomalies and 20 complex forms with risk factors such as interrupted aortic arch (n = 8), coarctation (n = 1), significant truncal valve regurgitation (n = 6), discontinuous pulmonary arteries (n = 3), and truncal valve stenosis (n = 2). There were 4 early deaths (4/42, 9.5%), with no difference between simple TA (2/22, 9.1%) and complex TA (2/20, 10%). Early mortality decreased to 1 patient (1/23, 4%) in the most recent era: 2003-2008. Late mortality occurred in 4 (4/38, 10.5%). Reintervention was required in 12 patients, a median of 2 years postoperatively: for conduit reasons in 8 and combined conduit and truncal valve insufficiency in 4. Actuarial survival was 82% ± 7% at 5 years and freedom from reintervention was 52% ± 17% at 5 years, which are not different between complex and simple forms. Complex TA, age, and weight were not predictors on multivariable analysis for early or late death or reintervention. Complex TA had significantly longer (P < .05) median length of stay (17 vs 13 days) and intensive care unit intubation times (8 vs 5 days) versus simple TA. Complex TA does not have a higher operative or late mortality risk or increased risk of reintervention compared with simple TA. However, complex patients can be expected to have increased resource utilization as compared with simple forms of TA.

Experience with the Levitronix CentriMag in the pediatric population as a bridge to decision and recovery.

Short-term mechanical circulatory support in the pediatric population with acute cardiac failure has traditionally been limited to extracorporeal membrane oxygenation given the limited availability of pediatric-sized pumps. The Levitronix CentriMag system (Thoratec Corporation, Pleasanton, CA, USA) offers expanded options for short-term support for this population. We report our experience with the successful use of the CentriMag in the pediatric population as a bridge to decision after postcardiotomy ventricular failure and as a bridge to recovery after heart transplantation. The first patient was bridged to a long-term HeartMate II (Thoratec Corporation) as a bridge to potential recovery. The second patient was supported after severe graft failure post heart transplantation, with a full recovery. The Levitronix CentriMag has proven to be a versatile, safe, and effective short-term circulatory support system for our pediatric patients.

Management of deep wound complications with vacuum-assisted therapy after Berlin Heart EXCOR ventricular assist device placement in the pediatric population.

Wound complications after ventricular assist device (VAD) placement remain a formidable challenge to surgeons. The Berlin Heart EXCOR VAD is a versatile pulsatile system that has been successful in pediatric patients of all ages and sizes. Prevention of device-related complications such as infection, particularly in pediatric patients, remains an essential issue in minimizing patient morbidity and mortality. The introduction of vacuum-assisted wound closure (VAC) therapy and its application in VAD-related wound complications provide an efficient and effective method for wound healing. We report our experience in the management of deep wound complications in two pediatric patients after placement of the Berlin Heart EXCOR VAD. The wound VAC system proved to achieve complete wound healing without any infectious complications.

Effect of red blood cell transfusion on oxygen consumption in the anemic pediatric patient.

OBJECTIVE: To compare oxygen consumption (Vo(2)) measured by indirect calorimetry before and after a packed red blood cell (PRBC) transfusion in patients with isovolemic anemia. DESIGN: Prospective, repeated-measures clinical study. SETTING: Outpatient pediatric hematology-oncology clinic. PATIENTS: A total of 17 pediatric hematology-oncology outpatients undergoing a PRBC transfusion for a hematocrit of <26%. INTERVENTIONS: Vo(2) was measured by indirect calorimetry before and after a PRBC transfusion. MEASUREMENTS AND MAIN RESULTS: Baseline hematocrit averaged 23% (15.5-25.7%), hemoglobin averaged 8.24 g/dL (5.2 g/dL-9.3 g/dL). Patients received an average of 10.3 mL/kg (2.8-17.5 mL/kg) of PRBC. After PRBC transfusion, all patients had an increase in Vo(2), with a mean increase of 35.09 mL x min(-1) x m(-2) (5-75 mL x min(-1) x m(-2)) or 19% (3.1-52%; p <.001). No significant correlation was found between the pretransfusion hematocrit or the volume of red blood cells administered and the change in Vo(2). No significant change was noted in systolic blood pressure or respiratory rate. There were 14 patients who had a decrease in heart rate after PRBC transfusion, and seven patients who demonstrated an increase in Vo(2) of <10% were compared with patients with a > or =10% change. No significant difference was found in age, height, weight, initial hematocrit, or volume of red blood cells transfused between these two groups. CONCLUSIONS: A significant increase in Vo(2) was noted after a red blood cell transfusion in pediatric patients with isovolemic anemia. These findings suggest that Vo(2) was dependent on the supply of oxygen in this subset of pediatric patients. Responding to increased oxygen delivery by increasing Vo(2) implies that these patients were functioning in a state of relative oxygen deficit and had made physiologic adaptive changes to function in this state.