Dissecting multidisciplinary cardiac surgery rounds.

BACKGROUND: Multidisciplinary rounds in the critical care environment have demonstrated increased communication, a reduction in medical errors, a shorter hospital stay, and consequently, economic savings. We attempt to assess the cost of this intervention, and to review the time utilization of professionals participating in the process. METHODS: We analyzed video-recorded weekly multidisciplinary teaching rounds on cardiac patients in a pediatric intensive care unit (n = 22). Rounding time was categorized as presentation or discussion and was measured in minutes. The cost of a round was calculated by multiplying the hourly salary of all healthcare professionals present by the time spent rounding and measured in US dollars. RESULTS: Median rounding time per patient was 15 minutes (range, 5 to 29). Patient presentation took between 2 and 8 minutes (median 4), or 26% of the rounding time. Time needed for discussion, including teaching and planning, varied between 2 and 25 minutes (median 10.5). Median number of participants was 13.5 (range, 11 and 16). Mean cost in salaries per patient rounded was $140.87 (95% confidence interval: $106.80 to $174.90). CONCLUSIONS: Multidisciplinary rounds are a low-cost medical intervention with proven benefits. Available tools and rounding cultural changes should be adopted to shorten data retrieval and presentation time to the benefit of discussion and teaching. Current billing requirements for rounding multidisciplinary teams do not reflect the realities of their time use.

Berlin heart as a bridge to recovery for a failing Fontan.

We report the temporary use of a Berlin Heart ventricular assist device (Berlin Heart AG, Berlin, Germany) for cardiac support of an 18-month-old girl with rapidly progressive ventricular failure after completion of a fenestrated Fontan. After 6 months of cardiac assistance with a single pneumatic pump, catheterization data showed improvement of the ventricular function and the ventricular assist device was successfully removed. A follow-up echocardiogram 6 months after hospital discharge demonstrated marked improvement of ventricular function.

Levels of vasopressin in children undergoing cardiopulmonary bypass.

OBJECTIVES: It is accepted treatment to give vasopressin to adults in postcardiotomy shock, but such use in children is controversial. Cardiopulmonary bypass is presumed to attenuate the normal endogenous vasopressin response to shock. We hypothesized that levels of vasopressin in children are altered by bypass, and that children having low endogenous levels perioperatively are more likely to develop hypotension, or require vasopressors. METHODS: Serial levels of vasopressin were assessed prospectively in children undergoing bypass at a single center. RESULTS: Of 61 eligible patients, we enrolled 39 (63%). Their median age was 5 months. The mean level of vasopressin prior to bypass was 18.6 picograms per millilitre, with an interquartile range from 2.6 to 11.4. Levels of vasopressin peaked during bypass at 87.1, this being highly significant compared to baseline (p < 0.00005), remained high for 12 hours at a mean of 73.5, again significantly different from baseline (p = 0.002), were falling at 24 hours, with a mean of 28.1 (p = 0.04), and had returned to baseline by 48 hours, when the mean was 7.4 (p = 0.3). Age, gender, and the category for surgical risk had no influence on the levels of vasopressin. There was no statistically significant relationship between the measured levels and hypotension or the requirement for vasopressors, although a few persistently hypotensive patients had high levels subsequent to bypass. Higher levels correlated with higher levels of sodium in the serum (r(s) = 0.37, p < 0.00005), higher osmolality (r(s) = 0.37, p < 0.00005), and positive fluid balance (r(s) = 0.23, p < 0.008). Preoperative use of inhibitors of angiotensin converting enzyme, preoperative congestive cardiac failure, and longer periods of bypass predicted higher levels during the first eight postoperative hours. CONCLUSIONS: Children do not have deficient endogenous levels of vasopressin following bypass, and lower levels are not associated with hypotension. Any therapeutic efficacy of infusion of vasopressin for post-cardiotomy shock in children is likely due to reasons other than physiologic replacement.