Total donor ischemic time: relationship to early hemodynamics and intensive care morbidity in pediatric cardiac transplant recipients.

OBJECTIVE: Single-center studies have failed to link modest increases in total donor ischemic time to mortality after pediatric orthotopic heart transplant. We aimed to investigate whether prolonged total donor ischemic time is linked to pediatric intensive care morbidity after orthotopic heart transplant. DESIGN: Retrospective cohort review. SETTING: Tertiary pediatric transplant center in the United Kingdom. PATIENTS: Ninety-three pediatric orthotopic heart transplants between 2002 and 2006. METHODS: Total donor ischemic time was investigated for association with early post-orthotopic heart transplant hemodynamics and intensive care unit morbidities. RESULTS: Of 43 males and 50 females with median age 7.2 (interquartile range 2.2, 13.0) yrs, 62 (68%) had dilated cardiomyopathy, 20 (22%) had congenital heart disease, and nine (10%) had restrictive cardiomyopathy. The mean total donor ischemic time was 225.9 (sd 65.6) mins. In the first 24 hrs after orthotopic heart transplant, age-adjusted mean arterial blood pressure increased (p < .001), mean pulmonary arterial pressure fell (p = .012), but central venous pressure (p = .58) and left atrial pressure (p = .20) were unchanged. After adjustment for age, primary diagnosis, pre-orthotopic heart transplant mechanical support, and marginal donor factors, longer total donor ischemic time was significantly associated with lower mean arterial blood pressure (p < .001) in the first 24 hrs after orthotopic heart transplant, longer post-orthotopic heart transplant mechanical ventilation (p = .03), longer post-orthotopic heart transplant stay in the intensive care unit (p = .004), and longer post-orthotopic heart transplant stay in hospital (p = .02). Total donor ischemic time was not related to levels of mean pulmonary arterial pressure (p = .62), left atrial pressure (p = .38), or central venous pressure (p = .76) early after orthotopic heart transplant. CONCLUSIONS: Prolonged total donor ischemic time has an adverse effect on the donor organ, contributing to lower mean arterial blood pressure, as well as more prolonged ventilation and intensive care unit and hospital stays post-orthotopic heart transplant, reflecting increased morbidity.

A Portable CT Scanner in the Pediatric Intensive Care Unit Decreases Transfer-Associated Adverse Events and Staff Disruption.

INTRODUCTION: Computerized tomography (CT) is an important diagnostic tool in the management of critically ill children, especially those with neurosurgical problems such as traumatic brain injury. Traditionally, such scans require transfer to the radiology department (RD) at times of extreme physiological instability, such as incipient cerebral herniation, and exposes children with actual, or potential, spinal injuries to the risks of transfer. Moving children from pediatric intensive care (PIC), often overnight, also depletes units of senior staff. Portable CT (PCT) scanning offers a solution to this problem, and we assessed patient stability and staff time occupied during urgent CT scans before and after the introduction of a PCT scanner (CereTom(®)) in a regional neurosurgical pediatric intensive care unit (PICU). MATERIALS AND METHODS: Prospective observational study of ventilated children in the PICU requiring urgent CT of the head to limit secondary brain injury. Data was collected for three months prior to, and for the same period after, the introduction of PCT on a questionnaire designed to assess physiological variables, PICU interventions, and staff time, which was completed immediately post scanning. RESULTS: Eight children had urgent CT head scan in the RD during the first 3 months and ten PCT in the second 6 months. The patients transferred to the RD required medical intervention because of cardio-respiratory instability or fluctuating intracranial pressure in nearly every patient and clearly increased the strain on staff resources. None of those patients undergoing PCT had untoward events and staff resources were far less impacted upon. DISCUSSION: PCT scanning is safe for unstable neurosurgical patients who need urgent diagnostic head CT, reducing the risks associated with transfer and the depletion of staff provision to the other children in the PICU. While this study did not specifically address image quality, all images were diagnostic regarding the indication for scanning.