No escape from a VSD device? Complete heart block and cardiac arrest associated with a ventricular septal defect occluder device.

A 15 month old boy with a ventricular septal defect (VSD) underwent percutaneous device closure of the VSD. Five days later he collapsed; on arrival to hospital he was asystolic and received prolonged cardio-pulmonary resuscitation (CPR) with intermittent return of spontaneous circulation (ROSC). He had recurrent episodic complete heart block with no ventricular escape rhythm, associated with loss of cardiac output, unresponsive to transcutaneous pacing. He was transferred to theatre, while receiving CPR, for urgent removal of the VSD device. Estimated total 'down time' was 70 min. The device was removed and patch closure of the VSD was performed. He made a full neurological recovery. Device closure of septal defects has become widespread. We discuss the incidence and type of arrythmias associated with their use. This case highlights an uncommon but life threatening complication of a VSD device. It also highlights that good quality CPR may lead to positive outcomes following pediatric cardiac arrest.

Epidemiology, clinical characteristics and resource implications of pandemic (H1N1) 2009 in intensive care units in Ireland.

OBJECTIVE: To describe the incidence, clinical characteristics and outcomes of critically ill patients in Ireland with pandemic (H1N1) 2009 infection, and to provide a dynamic assessment of the burden of such cases on Irish intensive care units. DESIGN, SETTING AND PARTICIPANTS: Multicentre prospective observational study of all adult patients admitted to any of the 30 ICUs in the Republic of Ireland between 15 July 2009 and 30 May 2010. MAIN OUTCOME MEASURES: Patient demographics, clinical characteristics and ICU mortality; ICU admissions, bed-days, bed occupancy rates and distribution. RESULTS: Seventy-seven adult patients with pandemic (H1N1) 2009 infection were admitted to 27 of 30 Irish ICUs. The median age was 43 years (IQR, 30-56 years); 67 patients (88%) were aged under 65; 39 (51%) were male. Sixty-two patients (82%) had comorbid conditions, including obesity (36%), respiratory disease (34%) and malignancy or immunosuppression (20%). Eight (11%) were pregnant, and 27 (36%) were smokers. Sixty-seven patients were mechanically ventilated, 24 (32%) required renal replacement therapy, 39 (51%) received vasopressors and four (5%) received extracorporeal membrane oxygenation. Of 14 patients (18%) who died in the ICU, two had no pre-existing comorbidities. The ICU admission rate of patients with pandemic (H1N1) 2009 infection was 22.5/million population. A total of 1882 ICU bed-days (557.5 bed-days/million adult population) were consumed, equating to a 3.9% bed occupancy rate, with a peak of 14.0% in October 2009. Median length of stay was 12 days (IQR, 7-34 days). CONCLUSION: The 2009 influenza A (H1N1) pandemic was a significant burden on Irish ICUs, predominantly affecting the tertiary centres. The demographics and clinical characteristics were similar to those described in the southern hemisphere, suggesting such data may inform future resource planning for similar threats.