Risk of in-hospital Deterioration for Children with Single Ventricle Physiology.

Children with single ventricle physiology (SV) are at high risk of in-hospital morbidity and mortality. Identifying children at risk for deterioration may allow for earlier escalation of care and subsequently decreased mortality.We conducted a retrospective chart review of all admissions to the pediatric cardiology non-ICU service from 2014 to 2018 for children < 18 years old. We defined clinical deterioration as unplanned transfer to the ICU or inpatient mortality. We selected children with SV by diagnosis codes and defined infants as children < 1 year old. We compared demographic, vital sign, and lab values between infants with and without a deterioration event. We evaluated vital sign and medical therapy changes before deterioration events.Among infants with SV (129 deterioration events over 225 admissions, overall 25% with hypoplastic left heart syndrome), those who deteriorated were younger (p = 0.001), had lower baseline oxygen saturation (p = 0.022), and higher baseline respiratory rate (p = 0.022), heart rate (p = 0.023), and hematocrit (p = 0.008). Median Duke Pediatric Early Warning Score increased prior to deterioration (p < 0.001). Deterioration was associated with administration of additional oxygen support (p = 0.012), a fluid bolus (p < 0.001), antibiotics (p < 0.001), vasopressor support (p = 0.009), and red blood cell transfusion (p < 0.001).Infants with SV are at high risk for deterioration. Integrating baseline and dynamic patient data from the electronic health record to identify the highest risk patients may allow for earlier detection and intervention to prevent clinical deterioration.

Extracorporeal Membrane Oxygenation for Hemodynamic Support.

Extracorporeal membrane oxygenation was first successfully achieved in 1975 in a neonate with meconium aspiration. Neonatal extracorporeal membrane oxygenation has expanded to include hemodynamic support in cardiovascular collapse before and after cardiac surgery, medical heart disease, and rescue therapy for cardiac arrest. Advances in pump technology, circuit biocompatibility, and oxygenators efficiency have allowed extracorporeal membrane oxygenation to support neonates with increasingly complex pathophysiology. Contraindications include extreme prematurity, extremely low birth weight, lethal chromosomal abnormalities, uncontrollable hemorrhage, uncontrollable disseminated intravascular coagulopathy, and severe irreversible brain injury. The future will involve collaboration to guide and evolve evidence-based practices for this life-sustaining therapy.

Extracorporeal membrane oxygenation support for hypertrophic cardiomyopathy in an infant of a diabetic mother.

Infants of diabetic mothers are at risk for transient hypertrophic cardiomyopathy. These infants are typically asymptomatic, but may develop signs of poor cardiac output from left ventricular outflow tract obstruction. This case illustrates the successful use of extracorporeal membrane oxygenation to support cardiac output in an infant of a diabetic mother with outflow tract obstruction until hypertrophy improved.

Implementation of a Multidisciplinary Bleeding and Transfusion Protocol Significantly Decreases Perioperative Blood Product Utilization and Improves Some Bleeding Outcomes.

Perioperative transfusion of blood products is associated with increased morbidity and mortality after pediatric cardiac surgery. We report the results of a quality improvement project aimed at decreasing perioperative blood product administration and bleeding after pediatric cardiopulmonary bypass (CPB) surgery. A multidisciplinary team evaluated baseline data from 99 consecutive CPB patients, focusing on the variability in transfusion management and bleeding outcomes, to create a standardized bleeding and transfusion management protocol. A total of 62 subsequent patients were evaluated after implementation of the protocol: 17 with single pass hemoconcentrated (SPHC) blood transfusion and 45 with modified ultrafiltration (MUF). Implementation of the protocol with SPHC blood led to significant decrease in transfusion of every blood product in the cardiovascular operating room and first 6 hours in cardiovascular intensive care unit ([CVICU] p < .05). Addition of MUF to the protocol led to further decrease in transfusion of all blood products compared to preprotocol. Patients <2 months old had 49% decrease in total blood product administration: 155 mL/kg preprotocol, 117 mL/kg protocol plus SPHC, and 79 mL/kg protocol plus MUF (p < .01). There were significant decreases in postoperative bleeding in the first hour after CVICU admission: 6 mL/kg preprotocol, 3.8 mL/kg protocol plus SPHC, and 2 mL/kg protocol plusMUF (p = .02). There was also significantly decreased incidence of severe postoperative bleeding (>10 mL/kg) in the first CVICU hour for protocol plus MUF patients (p < .01). Implementation of a multidisciplinary bleeding and transfusion protocol significantly decreases perioperative blood product transfusion and improves some bleeding outcomes.

Preoperative trophic feeds in neonates with hypoplastic left heart syndrome.

OBJECTIVE: The aim of this is study is to determine if preoperative trophic feeds (TFs) can improve outcomes after Norwood palliation. DESIGN: This is a retrospective cohort study. SETTING: The setting is a pediatric cardiovascular intensive care unit in a tertiary hospital. PATIENTS: The patients were 50 consecutive patients with hypoplastic left heart, excluding 5 patients with prematurity or other significant comorbidities. Thirty-one patients that received preoperative TFs (20-30 mL/kg) were compared with 14 that remained nothing by mouth. Decision to initiate feeds was based on attending preference. All patients had protocolized feeds postoperatively, with initiation via transpyloric tube when patient was on minimal inotropes. OUTCOME MEASURES: Demographic, feeding, and other clinical outcome data were collected retrospectively from the patient medical record. RESULTS: There were no differences in demographics or preoperative risk factors (mechanical ventilation and lowest pH) between the two groups. Overall survival to discharge was 78% (25/31 TF, 10/14 nothing by mouth, P = .7). Neonates receiving TFs had less fluid administration in the cardiovascular operating room (P = .002), a more negative 48-hour postoperative fluid balance (P = .03), and median 3 days shorter duration of mechanical ventilation (P = .006). Trophic feeds patients also had a nonsignificant trend toward lower peak lactic acid (P = .06), lower inotropic score (P = .15), shorter hospital length of stay (P = .19), and faster time to tolerance of full enteral and oral feeds by 3 and 8 days, respectively (P = .06 and .01). There were no episodes of necrotizing enterocolitis in either group. CONCLUSIONS: Preoperative TFs before Norwood palliation appear safe and are associated with shorter duration of mechanical ventilation, a trend toward more stable postoperative hemodynamics, less fluid overload, and earlier postoperative feeding tolerance.

Response to a single dose of sildenafil in single-ventricle patients: an echocardiographic evaluation.

New evidence of increased phosphodiesterase-5 (PDE-5) in hypertrophied human myocardium suggests that sildenafil, a selective PDE-5 inhibitor, may improve muscle contraction and therefore improve ventricular function. The purpose of this study was to compare ventricular function as assessed by echocardiography in 10 surgically palliated single-ventricle patients at baseline and again after a single dose of sildenafil. The velocity time integral of the ventricular outflow tract was increased 2 h after sildenafil administration (p = 0.01), thus suggesting an improvement in cardiac output.

Side-arm grafts for femoral extracorporeal membrane oxygenation cannulation.

Lower extremity ischemia is an important source of morbidity with femoral venoarterial extracorporeal membrane oxygenation support. We describe our experience with the use of a side-arm graft sewn to the femoral artery that facilitates adequate extracorporeal membrane oxygenation flow while preventing lower extremity ischemia.