Conscious sedation in the pediatric population. Special considerations.

The child requiring sedation has unique needs. The nurse caring for pediatric patients must have adequate knowledge to incorporate the physical, emotional, and psychological differences between children and adults into the child's overall plan of care. Because of these differences, sedation of the child presents a challenge. The nurse must continue to assess his or her knowledge of all facets of sedative agents and monitoring principles in the pediatric population to provide safe, effective quality care to children and their families.

Care of adolescents and young adults with cardiac arrhythmias.

Cardiac arrhythmias in the adolescent and young adult population are being seen with increasing frequency by cardiovascular nurses who predominantly care for adults. These patients include those with anatomically normal hearts and those with postoperative congenital heart disease. The treatment options available to these patients vary according to the rhythm abnormality being treated. In order to provide expert care to these patients and their families, the cardiovascular nurse must be aware of these specific rhythm abnormalities, their associated treatment options, and the nursing implications of caring for this often vulnerable patient population.

Supraventricular tachycardia in children: a challenge for pediatric nurses.

Supraventricular tachycardia (SVT) in the pediatric population remains the most common dysrhythmia for this age group. Care of these children and their families can provide a challenge for the pediatric nurse as well as many rewards. This report will explore the mechanisms of SVT in children, their clinical presentation, currently available treatment options, and the nursing implications of caring for these children and their families.

Postoperative rhythm disturbances.

Cardiac dysrhythmias in children after repair of congenital heart disease continue to challenge pediatric cardiovascular health care professionals. These rhythm disturbances, both bradyarrhythmias and tachyarrhythmias, can occur acutely and resolve, or they may become chronic, warranting more aggressive therapy. This article presents an overview of these acute and chronic rhythm disturbances, their associated treatments and interventions, and the nursing implications of caring for these children and their families.

Actuarial survival of transvenous pacing leads in a pediatric population.

This study was undertaken to examine the actuarial survival of endocardial pacing leads in a pediatric population. We prospectively followed 148 children and young adults age 4 months to 38 years. Of these, 58 had normal cardiac anatomy and 90 had surgically corrected congenital heart disease. A total of 213 leads were inserted in these patients. Actuarial analysis showed that at 5 years 76.0% of the pacemaker leads were still in use. The reasons for abandonment included death (10), exit block (8), lead fracture (8), adapter malfunction (7), and other including infection, lead migration, and pacemaker malfunction (12). Excluding deaths, an actuarial survival curve was constructed. Stepwise discriminant analysis and independent measures of association showed a significant difference in lead abandonment when the leads placed in the atrium were compared to those placed in the ventricle (30 vs 5; P < 0.0005). Lead insulating material, cardiac anatomy, and/or indication for pacemaker placement had no statistically significant impact on lead survival.

Cardiac pacing in neonates, infants, and preschool children.

A series of 37 children < 5 years old at pacemaker implant were followed from 1 to 105 months. Five of 37 patients required reoperation for battery depletion while two required reoperation for exit block of epicardial ventricular leads. Each patient paced in the DDD or AAI mode was still in the original mode at the end of follow up.

Pediatric cardiac pacing.

Cardiac pacing in children has undergone many improvements in the last decade. The differences between adult and pediatric pacing have narrowed. Children are no longer being denied pacemakers because of size. This article discusses techniques for pacing pediatric patients successfully that will allow them to lead normal lives.

Atrioventricular pacing in congenital heart disease.

We have attempted to optimize cardiac performance in patients with congenital heart disease requiring artificial pacing by using pacemakers capable of both sensing and pacing both the atrium and the ventricle (DDD). We reviewed our results with 88 patients receiving DDD devices to determine the safety and dependability of these devices in children. Age ranged from 1 hour to 25 years. Endocardial leads were used in 68 patients, whereas epicardial leads were used in 20 patients. Previous cardiac procedures had been done in 30 patients. There were nine deaths but none due to pacemaker malfunction. Endocardial leads functioned better than epicardial leads. Ninety-eight percent of patients with endocardial leads and 62% of patients with epicardial leads were maintained in the DDD mode. Complications were infrequent and all were corrected without long-term sequelae. The DDD mode may offer considerable benefits to children who require artificial pacing. Our data allow us to conclude that most children can be paced safely and dependably in the DDD mode.

Flecainide toxicity in a neonate with supraventricular tachycardia.

Class IC antiarrhythmic drugs, specifically encainide and flecainide, have been used with increasing frequency in children and young adults with both atrial and ventricular tachyarrhythmias. As a result of the recent findings from the Cardiac Arrhythmia Suppression Trial (CAST) study, their use in adults as well as children has been questioned. Because of their potential and often dangerous side effects, the child receiving a class IC drug must be monitored very closely. We report a case of flecainide toxicity in a 2 1/2-week-old neonate who was being treated for incessant supraventricular tachycardia.

Atrial antitachycardia pacing in children and young adults.

Atrial antitachycardia pacing was tested in 23 children and young adults. The majority of these patients had had operative repair of congenital cardiac defects and had both bradycardia and tachycardia. Pacemakers were usually implanted by the transvenous technique using bipolar leads. In each patient it was possible to find a tachycardia termination algorithm that successfully converted the tachycardia. In some patients very complex algorithms were necessary. In each patient it was also possible to find an algorithm that successfully differentiated the abnormal tachycardia from sinus tachycardia. Twelve patients required no antiarrhythmic drugs after pacemaker implantation, while 10 patients required one drug and one patient required two drugs. Eight of 23 patients had symptomatic tachycardias that required reprogramming the pacemaker to a different tachycardia termination sequence. Seven patients required reoperations, five for adapter problems and two for infection or erosion. Cardiac function improved in 15 of the 23 patients. Antitachycardia pacing is a viable option for management of tachycardias in children and young adults.

Clinical and electrophysiological characteristics of ventricular tachycardia in children with normal hearts.

Characteristics of 18 patients with clinical ventricular tachycardia (VT) and normal hearts documented by physical examination, echocardiography, and angiocardiography were analyzed. There were 13 males and 5 females, aged 1 to 16 years (mean +/- SD, 9.7 +/- 4.8 years). Six patients had hemodynamic instability during VT and the other 12 patients were hemodynamically stable. Two patients (11%) presented with sustained VT and 16 (89%) with episodes of nonsustained VT at varying intervals (3 of 16 with repetitive monomorphic VT). Among 14 patients on whom exercise tests were performed, seven had exercise-induced VT. During electrophysiologic studies, VT was induced in 16 of 18 (89%) (in 13 patients with morphology identical to clinical VT). VT was induced by programmed stimulation (single, double, and burst stimulation of the right atrium or right ventricular apex during sinus rhythm or during pacind for eight beats) in 5 of 18 (28%) patients; with isoproterenol, VT was aggravated spontaneously in 6 of 15 (40%) patients; and during stimulation VT was induced in 8 of 15 (53%) patients. Among patients whose VT was not induced during programmed stimulation, VT was induced with the addition of isoproterenol in 11 of 12 (92%). All 14 patients in follow-up are in stable condition, seven patients with medication and seven without medication. Pediatric patients with normal hearts and clinically detected VT usually have VT induced by programmed stimulation, either with or without isoproterenol stimulation.

Is activity sensored pacing in children and young adults a feasible option?

Activity sensing pacemakers are being utilized with increasing frequency in adults, but less frequently in the pediatric and young adult age group. We evaluated 12 young patients with activity sensing devices. Seven of the implanted devices were VVIRO, four were DDDRO and one was AAIRO. Patients ranged in age from 1-21 years, mean 9.3 years, median 8 years. Weights ranged from 8.25 to 80 kgs, mean 35 kgs, median 27.6 kgs. Anatomical diagnoses revealed six normal hearts, two P/O tetralogy, one P/O transposition, two P/O ablations, and one P/O Fontan. Rhythm diagnoses included congenital complete atrioventricular block in five, acquired complete atrioventricular block in three, sinus bradycardia in two, and His-bundle catheter ablation in one patient. Rate responsive settings of medium and 7 were used in 10 out of 12 patients. Treadmill exercise testing showed that 5 out of 7 patients' rates were controlled by the activity sensor at peak exercise while two were tracking sinus rhythm (average rate increase was 76.8 ppm in the five patients). Ambulatory monitoring revealed that 10 out of 12 patients used their activity sensor to control their heart rate (average rate increase was 54 ppm). Follow-up has ranged from 1-26 months, mean 6.8 months, median 5.5 months. There was one death. Effective rate modulated, activity sensing pacing was achieved in 7 out of 9 young patients. It should be considered when the atrium itself is not a feasible sensor.

New approaches to treatment of incessant ventricular tachycardia in the very young.

It was assumed that the availability of new antiarrhythmic drugs and new surgical techniques might allow medical or nonexcisional surgical treatment in many young children with incessant ventricular tachycardia. Fourteen infants and young children less than 5 years of age were evaluated and treated for incessant ventricular tachycardia. Medical treatment was pursued up to the use of amiodarone with a type Ib or Ic antiarrhythmic drug unless the patient became hemodynamically unstable. Patients underwent surgery when these drug regimens failed or when moderate congestive heart failure was present. Seven patients were successfully treated medically and seven underwent surgical treatment. Of those treated surgically, five had cryothermic lesions and two had excisions. Five of the surgically treated patients required temporary additional medical treatment. Follow-up ranged from 12 to 53 months (mean 28). Eleven of the 14 patients are currently not taking any antiarrhythmic medication. No patient required a pacemaker, none received anticongestive medications and none died.

Successful treatment of congenital atrial flutter with antitachycardia pacing.

Congential atrial flutter is a condition that rarely requires chronic pharmacological therapy. An unusual case of congenital atrial flutter is described which was resistant to medical therapy, yet responded well to antitachycardia pacing. While most experience with antitachycardia pacing in pediatrics has been with the postoperative congenital heart patient, patients such as the one described with unscarred atria may prove to be the most suitable pediatric candidates for this pacing modality.