Changing practice patterns for children with heart disease: a clinical pathway approach.

BACKGROUND: Pediatric cardiac care is costly and requires extensive resources. We studied the effect of clinical pathways on practice patterns and patient care outcomes in infants and children hospitalized for cardiac surgery. METHODS: In consecutive patients admitted for selected cardiac surgical procedures before (n = 69) and after (n = 173) implementation of clinical pathways, outcomes including hospital length of stay, days in the ICU, time to extubation, ordering of blood studies, costs, and readmissions were compared. Data were analyzed for each of five cardiac surgical procedures: repair of an atrial septal defect, repair of a ventricular septal defect, division of a patent ductus arteriosus, repair of tetralogy of Fallot, and neonatal arterial switch operation to correct transposition of the great arteries. RESULTS: A significant reduction in length of hospital stay, including days in the ICU (decreased 1 to 2 days per admission), was achieved after the clinical pathway was implemented. Reductions in average duration of mechanical ventilation ranged from 28% for repair of a ventricular septal defect to 63% for repair of tetralogy of Fallot. The number of blood studies ordered decreased 20% to 30%. A significant reduction in hospital costs for each procedure, ranging from 16% to 29%, was also achieved with no adverse effects on patients' outcomes. CONCLUSIONS: Use of clinical pathways with children hospitalized for cardiac surgery can shorten length of stay in the hospital, reduce use of resources, and improve cost-effectiveness with beneficial outcomes for patients.

Percutaneous catheter drainage of tension pneumatocele, secondarily infected pneumatocele, and lung abscess in children.

OBJECTIVE: To describe the use of percutaneous catheter drainage of tension pneumatocele, secondarily infected pneumatocele, and lung abscess in children. DESIGN: Retrospective case series. SETTING: A 24-bed pediatric intensive care unit. PATIENTS: Patients with tension pneumatocele, secondarily infected pneumatocele, or lung abscess. Tension pneumatocele was defined as an expanding intraparenchymal cyst compressing adjacent areas of the lung. Infected pneumatocele and lung abscess were defined, respectively, as intraparenchymal thin-walled cyst or thick-walled cavity containing an air-fluid level and purulent fluid. INTERVENTIONS: Seven pneumatoceles/lung abscesses were percutaneously drained in five patients. After computed tomography of the chest was obtained to localize the optimum site for drainage, a modified Seldinger technique was used to insert an 8.5-Fr soft catheter percutaneously into the cyst/cavity. The catheter was left in place until drainage (fluid and air) stopped. MEASUREMENTS AND MAIN RESULTS: All patients had clinical and radiologic improvement and were afebrile within 24 hrs after drainage. Bacterial culture grew aerobic bacteria from three cysts/cavities, anaerobic bacteria from one, and mixed bacteria from three. One patient had three secondarily infected pneumatoceles. Four of five secondarily infected pneumatoceles were under tension in two patients receiving mechanical ventilation. In both patients, the trachea was extubated within 24 hrs of drainage after prolonged mechanical ventilation. The number of days the catheter was in place ranged from 1 to 20 days. CONCLUSIONS: Percutaneous catheter drainage of tension pneumatocele, secondarily infected pneumatocele, and lung abscess can be performed safely and effectively in children. Early drainage is helpful, both as a diagnostic and therapeutic procedure. Drainage of tension pneumatocele may assist in weaning from mechanical ventilation. Computed tomography of the chest is helpful in determining the optimum site for percutaneous drainage.

Anaesthesia for children with junctional epidermolysis bullosa (letalis).

The anaesthetic management of two children with junctional epidermolysis bullosa, formerly called the letalis form, is described. Anaesthesia for children with this disease has not been described previously. Special precautions were taken to avoid mucosal injury and some customary monitoring devices were omitted. The previous anaesthetic literature, which discusses related but distinct forms of bullous skin diseases, is reviewed. The special concerns which relate to airway management in this disease are discussed.