Management of the Low Cardiac Output Syndrome Following Surgery for Congenital Heart Disease.

The purpose of this review is to discuss the management of the low cardiac output syndrome (LCOS) following surgery for congenital heart disease. The LCOS is a well-recognized, frequent post-operative complication with an accepted collection of hemodynamic and physiologic aberrations. Approximately 25% of children experience a decrease in cardiac index of less than 2 L/min/m2 within 6-18 hours after cardiac surgery. Post-operative strategies that may be used to manage patients as risk for or in a state of low cardiac output include the use of hemodynamic monitoring, enabling a timely and accurate assessment of cardiovascular function and tissue oxygenation; optimization of ventricular loading conditions; the judicious use of inotropic agents; an appreciation of and the utilization of positive pressure ventilation for circulatory support; and, in some circumstances, mechanical circulatory support. All interventions and strategies should culminate in improving the relationship between oxygen supply and demand, ensuring adequate tissue oxygenation.

Determining comorbidities and quality of life among pediatric survivors of extracorporeal life support.

PURPOSE: The purpose of this study is to describe health-related quality of life (HRQoL) and the prevalence of comorbidities in pediatric survivors of extracorporeal life support (ECLS) and to determine risk factors for poor HRQoL. MATERIALS: The study design was a retrospective cohort and prospective follow-up study of patients who received ECLS in the pediatric intensive care unit at Egleston Children's Hospital from 2006 to 2013. Quality of life was measured using the Pediatric Quality of Life Inventory (PedsQL 4.0) completed by either parent proxies or the survivors themselves. Clinical data were obtained via review of electronic medical records. RESULTS: Surveys were sent to 37 parent proxies or survivors with a response rate of 43.2%. Survivors ranged in age from 2 to 21 years with follow-up range of 1 to 7.5 years. Primary respiratory failure due to pneumonia was the reason for ECLS in 81.3%. Mean total PedsQL scores were 73.9 (±21.3) with 11 survivors (69.8%) having a normal quality of life. None of the clinical characteristics (including age, ECLS length, or length of stay) correlated with PedsQL scores. The most commonly reported comorbidities included readmission les than 1 year after ECLS (46.7%) and "problems with school" (25%). CONCLUSIONS: Survivors of pediatric extracorporeal membrane oxygenation can exhibit good HRQoL scores yet may be at risk for long-term adverse effects, such as lower psychosocial functioning and problems with school. A rigorous prospective investigation of the long-term follow-up of this patient cohort is needed to further evaluate these conclusions and to work toward the best possible outcomes for recipients of this resource-intensive therapy.

Factors associated with mortality in pediatric patients requiring extracorporeal life support for severe pneumonia.

OBJECTIVES: In children with respiratory failure secondary to pneumonia, extracorporeal life support can be lifesaving. Our goal was to identify variables associated with mortality in children with pneumonia requiring extracorporeal life support. DESIGN: Data query and abstraction from a multicenter, international registry of extracorporeal life support, the Extracorporeal Life Support Organization Registry. SETTING: Extracorporeal Life Support Organization registry data from 1985 to 2010. PATIENTS: Patients ≤ 18 yr of age who received extracorporeal life support for respiratory failure secondary to pneumonia. INTERVENTIONS: None. MEASUREMENTS AND OUTCOMES: Clinical variables, year of extracorporeal life support, and extracorporeal life support center location were collected. The primary outcome was survival at hospital discharge. Results are reported as predictive margins, which allow estimation of standardized mortality rates and differences for risk factors. RESULTS: One thousand four hundred eighty-nine children were included. The median (interquartile range) age and duration of extracorporeal life support were 5.7 months (2.5-21.5) and 11 days (7-18). Arterial cannulation was performed in 65% of patients. Mortality was 39%. There was no relationship between mortality and age or pathogen. Duration of extracorporeal life support had a biphasic relationship on mortality; mortality decreased 1.3% per day on extracorporeal life support until 14 days and then increased by 1.8% per day thereafter. Other independent predictors of mortality (p < 0.05) were pre-extracorporeal life support factors including duration of mechanical ventilation, peak inspiratory pressure, arterial oxygen saturation, pH, cardiac arrest, need for an arterial cannula, decade of extracorporeal life support, international extracorporeal life support center, and decrease in FIO2 over the first 24 hrs on extracorporeal life support. CONCLUSIONS: In children with severe pneumonia receiving extracorporeal life support, prognostic factors associated with increased risk of death included extracorporeal life support treatment exceeding 14 days, arterial cannulation, longer duration of mechanical ventilation, and decreased ability to wean ventilator FIO2 over the first 24 hrs on extracorporeal life support. Analysis of the Extracorporeal Life Support Organization registry can identify prognostic variables, which may influence medical decision making, resource utilization, and family counseling.

Resuscitation training in developing countries: a systematic review.

OBJECTIVE: To evaluate whether the inclusion of any specific resuscitation training educational strategy in developing countries improves outcomes. METHODS: As part of the International Liaison Committee on Resuscitation evidence evaluation process, a systematic review of the literature was conducted. The Cochrane database of systematic reviews; Medline; Google Scholar and EmBASE were searched using multiple search strategies. RESULTS: Forty-four papers were relevant to review, including 38 studies that provided support for the use of resuscitation training programs in developing countries. All studies that examined self-efficacy (15 studies) and student satisfaction (8 studies) reported improvement. There was no consistent testing method for educational outcomes across studies and few studies examined both educational outcomes and patient outcome (1 of 15 self-efficacy, 0 of 18 cognitive knowledge, 0 of 8 psychomotor skills, 0 of 5 simulated operational performance). Fourteen of 15 studies that examined patient survival were either newborn or trauma resuscitation, 1 adult resuscitation, and none were in pediatric resuscitation. Increased patient survival after resuscitation training was variable, with an absolute risk reduction that ranged from 0% to 34%. CONCLUSIONS: Resuscitation training in developing countries was well received and viewed as valuable training by the students and local counterparts. Important student, training environment characteristics, educational outcomes and patient outcomes were inconsistently defined and reported. Institution of training in trauma and newborn resuscitation in developing countries has significantly reduced mortality, but this has not been demonstrated with other training programs.