Search

Arginine vasopressin (AVP) is used to treat hypotension. Because AVP increases blood pressure (BP) by increasing systemic vascular resistance, it may have an adverse effect on tissue oxygenation following the Norwood procedure (NP).

The American Heart Association (AHA) recommends an initial defibrillation energy dose of 2 J/kg to treat pediatric in-hospital cardiac arrest (IHCA) with initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). However, the optimal energy dose remains unclear.Methods:Using data from the AHA Get With the Guidelines-Resuscitation?, we identified children ?12 years with IHCA and an initial arrest rhythm of VF/pVT. Current Pediatric Basic Life Support guidelines recommend weight-based defibrillation for these pre-pubertal children. Primary exposure was energy dose in joules/kilogram (J/kg), calculated by dividing recorded energy (J) by recorded weight (kg). To account for rounding errors, we categorized energy doses as follows: 1.7-2.5 J/kg as reference (reflecting a 2 J/kg intended energy dose), <1.7 J/kg and >2.5 J/Kg. The latter two categories were combined for sample size considerations. We compared survival for initial energy doses of 1.7-2.5 J/kg to all other doses. We constructed multivariable logistic regression models to test the association of energy dose with survival, adjusting for age, arrest location, illness category, initial rhythm and vasoactive medications.Results:We identified 301 patients ?12 years with index IHCA and initial VF or pVT. 4% of patients ?12 had energy ?120 J, the recommended initial adult dose. Survival to hospital discharge was significantly lower when energy doses other than 1.7-2.5 J/kg were used (adjusted odds ratio [aOR] 0.64; 95% confidence interval [CI] 0.44-0.89; p<0.01). Individual dose categories of either <1.7 J/kg (aOR 0.73 95% CI 0.47-1.15; p=0.18) or >2.5 J/kg (aOR 0.55 95% CI 0.29-1.04; p=0.06), were not associated with differences in survival to discharge compared to 1.7-2.5 J/kg. In sensitivity analysis of patients with initial VF (n=170), an initial energy dose >2.5 J/kg was associated with worse survival (aOR 0.44, 95% CI 0.21-0.90; P=0.03), compared to an initial dose of 1.7-2.5 J/kg.Conclusions:Initial energy doses other than 2 J/kg for IHCA presenting with VF/pVT are associated with worse survival to hospital discharge in patients ?12 years. Results support current AHA guidelines of initial energy dose of 2 J/kg in preadolescent patients and those with initial VF.

Background:Increasing numbers of adult congenital heart disease (ACHD) patients undergo cardiac surgery in children?s hospitals. Surgical outcomes data for ACHD patients at pediatric hospitals are limited.Objective:To identify predictors of prolonged cardiac intensive care unit (CICU) length of stay (pLOS) and major postoperative complications (mComp) following ACHD cardiac surgery at pediatric hospitals.Methods:Surgical encounters of patients >18 years in the Pediatric Cardiac Critical Care Consortium (PC4) registry (8/2014-1/2019; 34 hospitals) were included. Primary outcomes included pLOS (defined as LOS ? 90thpercentile) and mComp (cardiac arrest, ECMO, arrhythmia requiring intervention, stroke, renal replacement therapy, infection, reoperation/reintervention).Results:A total of 1773 surgical encounters were analyzed. The pLOS cutoff was >7 days. Eighteen patients (1.0%) died during hospitalization, 9 (0.5%) of whom died before the pLOS cutoff and were excluded from analysis. Of 1764 encounters, 8.8% (n=156) had pLOS and 23.3% (n=413) had >1 mComp. Predictors of primary outcomes identified in multivariable analysis are shown in Figure 1. STAT 4/5 operation, >3 previous sternotomies, and preoperative renal dysfunction/dialysis were significant risk factors for both pLOS and complications. Preoperative ventilation increased odds of pLOS while preoperative arrhythmias increased odds of mCOMP.Conclusions:In this analysis of postoperative ACHD care in pediatric CICUs contributing data to PC4, preoperative arrhythmias, renal dysfunction, and respiratory failure are potentially modifiable factors associated with pLOS and/or mComp. STAT 4/5 procedures and >3 previous sternotomies were also associated with both pLOS and mComp. Future quality improvement initiatives focused on preoperative optimization and implementation of adult-specific perioperative protocols may mitigate morbidity in this growing patient population.

Introduction:Predicting post-operative ICU length of stay (LOS) after congenital heart surgery (CHS) could inform scheduling, improve capacity management and model resource use variation.Hypothesis:A prediction model including patient characteristics and operative complexity at post-operative ICU admission can accurately predict ICU LOS >7 days. The model could be used to explore institutional differences in LOS.Methods:CHS admissions to 31 Pediatric Cardiac Critical Care Consortium (PC4) centers from April 2014 - September 2018 were identified. Hierarchical logistic regression with center-specific random intercepts identified variables associated with ICU LOS >7 days. The final model was used to compare risk-adjusted rates of ICU LOS>7 days across centers.Results:Of 29,113 CHS ICU admissions, 22.9% of the cohort had ICU LOS >7 days (range 1.8 - 41.2% by center). Important predictors of ICU LOS>7 days were STAT category (C=0.796) and pre-operative status (C=0.803), a descriptive composite of age, pre-operative mechanical ventilation, and pre-operative admission. Together, STAT category and pre-operative status were powerful predictors of ICU LOS>7 days (C=0.848, Table). Incorporation of post-operative characteristics of illness severity did not improve the model. Risk-adjusted rates for ICU LOS >7 days ranged from 10.8% to 40.5% (Figure).Conclusions:We developed a model to predict ICU LOS >7 days at postoperative ICU admission with excellent discrimination. We observed 4-fold variability in case-mix adjusted rates of ICU LOS>7 days across 31 centers. Further investigation is required to understand best practices and inform future quality initiatives.