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OBJECTIVE: Pediatric consensus-driven cardiopulmonary resuscitation guidelines target chest compression (CC) depths of one third to one half anterior-posterior (AP) chest depth. Estimates for this target as assessed by computed tomography (CT) measurements of internal and external AP chest dimensions could direct future pediatric cardiopulmonary resuscitation guidelines. METHODS: A total of 280 consecutive chest CT scans in permuted blocks of 20 for each of 14 age divisions between 0 and 8 years were reconstructed and analyzed. External and internal AP depths were measured at midsternum, and residual chest depth was calculated at simulated one-third and one-half AP compressions. RESULTS: After a simulated compression calculation, one-half external AP depth CC would result in residual internal depth of <10 mm for 94% (263 of 280) of children 3 months to 8 years. For a one-third external AP CC, only 0.4% (1 of 280) of children 3 months to 8 years had a calculated residual internal chest depth <10 mm. CONCLUSIONS: By using CT reconstruction estimates of chest dimensions across the developmental spectrum from 0 to 8 years of age, we demonstrated that a simulated CC targeting approximately one-third external AP chest depth seems radiographically appropriate for children aged 3 months to 8 years, whereas simulated CC targeting approximately one-half external AP chest depth seems radiographically to be too deep, resulting in residual internal chest depth of <10 mm for most patients of this age. [ABSTRACT FROM AUTHOR]

The Omega-3 Index (O3I) is the red blood cell (RBC) eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) content expressed as a percentage of total RBC fatty acids. Although a validated biomarker of omega-3 status in humans, little is known about the O3I status of dogs and cats; species in which omega-3 fatty acids have known health benefits. The purpose of this study was to develop equations to predict the O3I in these species from a dried blood spot (DBS) analysis. Random blood samples from 33 dogs and 10 cats were obtained from a community veterinary clinic. DBS and RBC samples were analyzed for fatty acid composition. For both species, the R2 between the DBS EPA + DHA value and the O3I was >0.96 (p < 0.001). The O3I was roughly 75% lower in dogs and cats than in humans. We conclude that the O3I can be estimated from a DBS sample, and the convenience of DBS collection should facilitate omega-3 research in these companion animals.

Background: The Omega-3 Index is a test that measures the amount of the long-chain omega-3 polyunsaturated fatty acids (n-3 PUFAs), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in red blood cell membranes, which is expressed as a percentage of all fatty acids. However, alpha-linolenic acid (ALA) from flaxseed oil, which is a short-chain n-3 PUFA, is often promoted in pet feed as a n-3 source, implicitly assuming it is an effective precursor of EPA and DHA., Objective: This study was aimed to compare the effect of supplementation with a plant-based short-chain n-3 PUFA source (flaxseed oil, FSO) with a marine long-chain n-3 PUFA source (astaxanthin krill oil, AKO) to increase the Omega-3 Index in dogs., Methods: Ten adult Alaskan Huskies of both genders were supplemented daily with 1,155 mg of EPA/DHA from AKO, whereas another 10 dogs received 1,068 mg ALA from flaxseed oil for 6 weeks. Fatty acid and Omega-3 Index measurements of the two groups were taken after 0, 3 and 6 weeks for comparison., Results: The EPA and DHA concentrations increased significantly only in the dogs fed with AKO resulting in a significant increase in mean Omega-3 Index, from 1.68% at baseline to 2.7% after 6 weeks of supplementation (p < .0001). On the contrary, both EPA and DHA concentrations decreased significantly in the dogs fed with FSO, which led to a significant decrease in mean Omega-3 Index from 1.6% at baseline to 0.96% at study end (p < .0001)., Conclusions: The results showed that supplementation of AKO from Antarctic krill led to a significant increase in the Omega-3 Index in comparison to FSO in dogs. This suggests that preformed marine EPA and DHA sources are needed in dog feeds, as the dietary requirements proposed by feed industry organizations are not met with conversion from short-chain n-3 fatty acids., (© 2020 The Authors. Veterinary Medicine and Science Published by John Wiley & Sons Ltd.)

Objectives: To evaluate the effectiveness of two scoring systems, the inadequate oxygen delivery index, a risk analytics algorithm (Etiometry, Boston, MA) and the Low Cardiac Output Syndrome Score, in predicting adverse events recognized as indicative of low cardiac output syndrome within 72 hours of surgery., Design: A retrospective observational pair-matched study., Setting: Tertiary pediatric cardiac ICU., Patients: Children undergoing cardiac bypass for congenital heart defects. Cases experienced an adverse event linked to low cardiac output syndrome in the 72 hours following surgery (extracorporeal membrane oxygenation, renal replacement therapy, cardiopulmonary resuscitation, and necrotizing enterocolitis) and were matched with a control patient on criteria of procedure, diagnosis, and age who experienced no such event., Interventions: None., Measurements and Main Results: Of a total 536 bypass operations in the study period, 38 patients experienced one of the defined events. Twenty-eight cases were included in the study after removing patients who suffered an event after 72 hours or who had insufficient data. Clinical and laboratory data were collected to derive scores for the first 12 hours after surgery. The inadequate oxygen delivery index was calculated by Etiometry using vital signs and laboratory data. A modified Low Cardiac Output Syndrome Score was calculated from clinical and therapeutic markers. The mean inadequate oxygen delivery and modified Low Cardiac Output Syndrome Score were compared within each matched pair using the Wilcoxon signed-rank test. Inadequate oxygen delivery correctly differentiated adverse events in 13 of 28 matched pairs, with no evidence of inadequate oxygen delivery being higher in cases (p = 0.71). Modified Low Cardiac Output Syndrome Score correctly differentiated adverse events in 23 of 28 matched pairs, with strong evidence of a raised score in low cardiac output syndrome cases (p < 0.01)., Conclusions: Although inadequate oxygen delivery is an Food and Drug Administration approved indicator of risk for low mixed venous oxygen saturation, early postoperative average values were not linked with medium-term adverse events. The indicators included in the modified Low Cardiac Output Syndrome Score had a much stronger association with the specified adverse events.

This manuscript provides a global perspective on physician and nursing education and training in paediatric cardiac critical care, including available resources and delivery of care models with representatives from several regions of the world including Africa, Israel, Asia, Australasia, Europe, South America, and the United States of America.

Background: The optimal treatment for fetal supraventricular tachycardia (SVT) with 1:1 atrioventricular relationship is unclear., Objective: We compared the effectiveness of transplacental treatment protocols used in 2 centers., Methods: Pharmacologic treatment was used in 84 fetuses. Maternal oral flecainide was the primary therapy in center 1 (n = 34) and intravenous maternal digoxin in center 2 (n = 50). SVT mechanism was classified by mechanical ventriculoatrial (VA) time intervals as short VA or long VA. Treatment success was defined as conversion to sinus rhythm (SR), or rate control, defined as >15% rate reduction., Results: Short VA interval occurred in 67 fetuses (80%) and long VA in 17 (20%). Hydrops was present 28 of 84 (33%). For short VA SVT, conversion to SR was 29 of 42 (69%) for digoxin and 24 of 25 (96%) for flecainide (P = .01). For long VA SVT, conversion to SR and rate control was 4 of 8 (50%) and 0 of 8, respectively, for digoxin, and 6 of 9 (67%) and 2 of 9 (cumulative 89%) for flecainide (P = .13). In nonhydropic fetuses, digoxin was successful in 23 of 29 (79%) and flecainide in 26 of 27 (96%) (P = .10). In hydrops, digoxin was successful in 8 of 21 (38%), flecainide alone in 6 of 7 (86%, P = .07 vs digoxin), and flecainide ± amiodarone in 7 of 7 (100%) (P = .01). Intrauterine or neonatal death occurred in 9 of 21 hydropic fetuses treated with digoxin (43%), compared to 0 of 7 (P = .06) treated with flecainide., Conclusions: Flecainide was more effective than digoxin, especially when hydrops was present. No adverse fetal outcomes were attributed to flecainide., (Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the incidence and severity of right ventricular dysfunction (RVD) in pediatric ventricular assist device (VAD) recipients and to identify the preoperative characteristics associated with RVD and their effect on outcomes., Methods: Children bridged to transplantation from 2004 to 2011 were included. RVD was defined as the use of a left VAD (LVAD) with an elevated central venous pressure of >16 mm Hg with inotropic therapy and/or inhaled nitric oxide for >96 hours or biventricular assist (BiVAD)., Results: A total of 57 children (median age, 2.97 years; range 35 days to 15.8 years) were supported. Of the 57, 43 (75%) had an LVAD, and of those, 10 developed RVD. The remaining 14 (25%) required BiVAD. Thus, RVD occurred in 24 of 57 patients (42%). Preoperative variables such as younger age (P = .01), use of extracorporeal mechanical support (P = .006), and elevated urea (P = .03), creatinine (P = .02), and bilirubin (P = .001) were associated with RVD. Multiple logistic regression analysis indicated that elevated urea and extracorporeal mechanical support (odds ratio, 26.4; 95% confidence interval, 2.3-307.3; and odds ratio, 27.8; 95% confidence interval, 2.5-312.3, respectively) were risk factors for BiVAD. The patients who developed RVD on LVAD had a complicated postoperative course but excellent survival (100%), comparable to those with preserved right ventricular function (91%). The survival for those requiring BiVAD was reduced (71%)., Conclusions: RVD occurred in approximately 40% of pediatric VAD recipients and affects their peri-implantation morbidity and bridging outcomes. Preoperative extracorporeal membrane oxygenation and elevated urea were risk factors for BiVAD. Additional studies of the management of RVD in children after VAD implantation are warranted., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Studies have shown improved perioperative outcomes after neonatal heart surgery at centers with greater surgical volumes. The impact of increasing distance from such centers on outcome after discharge has not yet been reported. Chart review and cross-sectional survey were performed on children discharged or transferred after undergoing neonatal congenital heart surgery as neonates (<30 days of age) from January 2005 to June 2006. The association of distance from center with mortality and adverse events was analyzed by univariate and multivariate regression and stratified by the Risk Adjustment for Congenital Heart Surgery-1 for complexity. Among 217 patients, those living further from the surgical center were smaller and older at surgery and more likely to be RACHS-1 class 6. Overall mortality was 8% (16 of 202) and was not associated with distance. Surveys were completed by 109 (54%) families with mean follow-up of 24 (± 3) months. Unplanned admissions after discharge and unplanned interventions occurred in 45% and 40% of patients, respectively. After adjusting for case complexity, living 90-300 min away from the surgical center was associated with fewer unplanned admissions compared with those living <90 min away. After neonatal cardiac surgery, adverse events were common. Distance from the surgical center was not associated with mortality, but it was associated with morbidity in a nonlinear fashion. This relation, its mediators, and its possible impact on mortality and later outcomes warrant further study to aid in planning appropriate patient follow-up.

Objective: To determine the incidence, risk factors, and outcomes after early, unplanned intervention on systemic-to-pulmonary artery shunts in neonates., Methods: We retrospectively studied all neonates undergoing systemic-to-pulmonary artery shunt placement at The Children's Hospital of Philadelphia between September 1, 2002, and May 1, 2005. Patients requiring transcatheter or surgical systemic-to-pulmonary artery shunt intervention before discharge were compared with those not undergoing shunt intervention., Results: A total of 206 patients underwent shunt placement. Diagnoses included hypoplastic left heart syndrome (62.1%), pulmonary atresia (15%), tricuspid atresia (4.9%), tetralogy of Fallot (2.4%), and other lesions with obstruction to systemic (10.7%) or pulmonary blood flow (4.9%). Twenty-one interventions occurred in 20 patients (9.7%). Risk factors for intervention included heterotaxy syndrome (P = .04), congenital abnormality (P = .04), and a trend toward lower birthweight. In patients with a modified Blalock-Taussig shunt, similar risk factors were identified and the incidence of intervention decreased with increasing shunt size. In-hospital mortality was 30% (6/20) for the cases and 8.1% (15/186) for the nonintervention group (P = .02). Long-term survival was significantly lower in patients requiring intervention (P = .002). This group also had a higher incidence of infections (P < .001) and extracorporeal membrane oxygenation (P < .001), and longer hospital stay (P = .001)., Conclusions: In neonates undergoing systemic-to-pulmonary artery shunt placement, approximately 10% underwent shunt intervention before discharge. Some factors, such as low birthweight, shunt size, noncardiac congenital abnormalities, and heterotaxy syndrome, may help identify patients at risk. Patients undergoing intervention experienced increased morbidity and mortality., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Catheter-associated bloodstream infections (CA-BSIs) are an important complication of care in children hospitalized with complex congenital heart disease; however, little is known about risk factors for CA-BSI in these patients., Methods: We conducted a retrospective nested case-control study in the 26-bed Cardiac Intensive Care Unit (CICU) at the Children's Hospital of Philadelphia.We identified all primary CA-BSIs in the CICU between January 1, 2004 and June 30, 2005. Controls were selected from rosters of CICU patients that were admitted during the same time period. Incidence density sampling was used to match cases and controls on time at risk. Data on demographic features and clinical characteristics were abstracted from the medical record. In addition, detailed data on exposures to medical devices, interventions, and therapeutic agents were gathered during a 4-day period immediately before the onset of infection (cases) or study entry (controls)., Results: We identified 59 children who developed a CA-BSI. The median time from catheter insertion to onset of infection was 9 days. Over half of infections were caused by gram positive organisms. On multivariable analysis, only tunneled catheters emerged as an independent risk factor for infection., Conclusion: In this study population, tunneled catheters were associated with a higher risk of CA-BSI, possibly because of the catheter material. Additionally, we did not find that the burden of catheters and medical devices was associated with an increased risk of infection. Because most CA-BSIs in our study population occurred > or =7 days after catheter insertion, strict attention to aseptic technique when using or dressing a catheter might reduce CA-BSI rates in the pediatric CICU.

Objective: To determine the effect of reintervention for coarctation after stage 1 reconstruction for hypoplastic left heart syndrome and variants on survival, suitability for Fontan, and morbidity at Fontan., Methods: A retrospective review of echocardiograms, catheterizations, hospital records of patients who underwent stage 1 reconstruction from January 2002 to May 2005, with a cross-sectional analysis of hospital survivors, was performed. Kaplan-Meier curves were derived for patients alive more than 30 days after stage 1 reconstruction., Results: A total of 176 patients underwent stage 1 reconstruction. Forty-three patients (23%) underwent balloon angioplasty (n = 43) or surgical intervention (n = 4) for re-coarctation. Median time to intervention was 123 (1-316) days. Seven of 43 patients (16%) underwent more than 1 balloon angioplasty. Thirty-nine patients underwent intervention before stage 2 reconstruction, and 4 patients had intervention between stage 2 reconstruction and Fontan. Kaplan-Meier curves showed no difference in freedom from death or transplant between patients who did and did not undergo intervention for re-coarctation. Fontan completion was performed in 107 patients. By echocardiogram, the prevalence of moderate to severe ventricular dysfunction between groups was similar at Fontan; however, significant atrioventricular valve regurgitation was more common in patients who required intervention (28/33 vs 40/65, P = .02). Overall Fontan mortality was 2% and not different between groups. Length of stay was not different between patients with and without re-coarctation., Conclusions: Reintervention for coarctation after stage 1 reconstruction is common. Hemodynamic differences between groups did not affect Fontan completion, mortality, or hospital length of stay. Follow-up is necessary to determine the impact of re-coarctation on longer-term mortality and morbidity., (2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: We previously reported no difference in morbidity or mortality in a cohort of infants undergoing stage 1 and 2 reconstructions for hypoplastic left heart syndrome with either a modified Blalock-Taussig shunt or a right ventricular to pulmonary artery conduit. This article compares the hemodynamics and perioperative course at the time of the Fontan completion and reports longer-term survival for this cohort., Methods: We retrospectively reviewed the hospital records of all patients who underwent stage 1 reconstruction between January 2002 and May 2005 and subsequent surgical procedures, as well as cross-sectional analysis of hospital survivors., Results: A total of 176 patients with hypoplastic left heart syndrome or a variant underwent stage 1 reconstruction with either modified Blalock-Taussig shunt (n = 114) or right ventricular to pulmonary artery conduit (n = 62). Shunt selection was at the discretion of the surgeon. The median duration of follow-up was 58 months (range 1-87 months). By Kaplan-Meier analysis, shunt type did not influence survival or freedom from transplant at 5 years (right ventricular to pulmonary artery conduit 61%; 95% confidence limit, 47-72 vs modified Blalock-Taussig shunt 70%; 95% confidence limit, 60-77; P = .55). A total of 107 patients underwent Fontan (69 modified Blalock-Taussig shunts and 38 right ventricular to pulmonary artery conduits) with 98% (105/107) early survival. Patients with a right ventricular to pulmonary artery conduit shunt pre-Fontan had higher pulmonary artery (13 +/- 8 mm Hg vs 11 +/- 3 mm Hg, P = .026) and common atrial (8 +/- 2.3 mm Hg vs 6.8 +/- 2.7 mm Hg, P = .039) pressures. By echocardiography evaluation, there was more qualitative moderate to severe ventricular dysfunction (right ventricular to pulmonary artery conduit 31% [12/36] vs modified Blalock-Taussig shunt 17% [11/67], P = .05) and moderate to severe atrioventricular valve regurgitation (right ventricular to pulmonary artery conduit 40% [14/35] vs modified Blalock-Taussig shunt 16% [11/67], P = .01) in the right ventricular to pulmonary artery conduit group. Use of diuretic therapy, angiotensin-converting enzyme inhibition, reflux medications, and tube feedings were not different between groups. Overall, 5 patients underwent heart transplantation (right ventricular to pulmonary artery conduit 4 vs modified Blalock-Taussig shunt 1, P = .1) before Fontan. There was no difference in age or weight at Fontan, bypass time, intensive care unit or hospital length of stay, postoperative pleural effusions, or need for reoperation between groups., Conclusions: Interim analyses continue to suggest there is no survival advantage of one shunt type compared with the other. Longer-term follow-up of a randomized patient population remains of utmost importance., (2010. Published by Mosby, Inc.)

Objective: Low weight at birth is a risk factor for increased mortality in infants undergoing surgery for congenitally malformed hearts. There has been a trend towards performing surgery in patients early, and for amenable lesions, in a single stage rather than following initial palliative procedures. Our goal was to report on the current incidences of morbidities and mortality in infants born with low weight and undergoing surgery for congenital cardiac disease., Methods: We made a retrospective review of the data from patients meeting our criterions for entry from July, 2000, through July, 2004. The criterions for inclusion were weight at birth less than or equal to 2500 grams, and congenital cardiac malformations requiring surgery during the initial hospitalization. A criterion for exclusion was isolated persistent patency of the arterial duct. We assessed preoperative, intraoperative, and postoperative variables., Results: We found a total of 105 patients meeting the criterions for inclusion. The median weight at birth was 2130 grams, and median gestational age was 36 weeks. The most common morbidity identified was infections of the blood stream. Infections, and chronic lung disease, were associated with increased length of stay. Survival overall was 76%. Patients with hypoplastic left heart syndrome, or a variant thereof, had the lowest survival, of 62%. The needs for cardiopulmonary resuscitation, or extracorporeal membrane oxygenation, post-operatively were the only factors identified as independent risk factors for mortality., Conclusion: Patients undergoing surgery during infancy for congenital cardiac disease who are born with low weight have a higher mortality and morbidity than those born with normal weight.

Background: Prenatal ventricular size discrepancy with disproportionately smaller left ventricle than right ventricle (L-R/VD) can be a marker for important left-sided structural heart disease in the newborn., Methods: We reviewed the echocardiograms of all fetuses evaluated at our center with L-R/VD from July 1, 2004 to January 1, 2008., Results: Of the 35 fetuses, 20 (57%) had critical arch obstruction and underwent neonatal intervention (group 1); 15 (43%) did not require newborn intervention (group 2). Ratios comparing left with right heart structures were significantly lower in group 1 fetuses compared with group 2 fetuses. Aortic arch measurement

Objective: Hyperglycaemia has been associated with worse outcome following traumatic brain injury and cardiac surgery in adults. We have previously reported no relationship between early postoperative hyperglycaemia and worse neurodevelopmental outcome at 1 year following biventricular repair of congenital heart disease. It is not known if postoperative hyperglycaemia results in worse neurodevelopmental outcome after infant cardiac surgery for single-ventricle lesions., Methods: Secondary analysis of postoperative glucose levels in infants <6 months of age undergoing Stage I palliation for various forms of single ventricle with arch obstruction. The patients were enrolled in a prospective study of genetic polymorphisms and neurodevelopmental outcomes assessed at 1 year of age with the Bayley Scales of Infant Development-II yielding two indices: mental developmental index (MDI) and psychomotor developmental index (PDI)., Results: Stage I palliation was performed on 162 infants with 13 hospital and 15 late deaths (17.3% 1-year mortality). Neurodevelopmental evaluation was performed in 89 of 134 (66.4%) survivors. Glucose levels at admission to the cardiac intensive care unit and during the first 48 postoperative hours were available for 85 of 89 (96%) patients. Mean admission glucose value was 274+/-91 mg dl(-1); the maximum was 291+/-90 mg dl(-1), with 69 of 85 (81%) patients having at least one glucose value >200 mg dl(-1). Only two patients had a value <50 mg dl(-1). Mean MDI and PDI scores were 88+/-16 and 71+/-18, respectively. There were no statistically significant correlations between initial, mean, minimum or maximum glucose measurements and MDI or PDI scores. Only delayed sternal closure resulted in a statistically significant relationship between initial, minimum and maximum glucose values within the context of a multivariate analysis of variance model., Conclusions: Hyperglycaemia following Stage I palliation in the neonatal period was not associated with lower MDI or PDI scores at 1 year of age.

Introduction: Our clinical observation indicates that some children who have a tracheostomy may experience increasing head circumference as they grow and develop. Accurate assessment and interpretation of growth parameters is an essential component of following child development. Appreciation for variations in growth is especially important in special populations, such as children with a tracheostomy. The aim of this study is to define head growth in children with a tracheostomy., Method: This retrospective cohort study includes children who underwent tracheostomy tube placement prior to 2 years of age in a respiratory rehabilitation unit within a children's hospital. Serial head circumference measurements were plotted against age on growth charts adjusted for gestational age. The percentage of patients with accelerated head growth, defined as increased head circumference across two major percentiles within 6 months following tracheostomy, was determined., Results: Fifty-seven percent (20 out of 35 children) demonstrated increased head circumference across two major percentiles within 6 months following tracheostomy., Discussion: Accelerated head growth is associated with the presence of a tracheostomy tube in children in this study. Further investigation is warranted to establish the relationship of head circumference to other growth parameters. In addition, the etiology of this phenomenon requires additional study. Understanding head growth in children with a tracheostomy will promote adequate growth assessment and may lead to improved patient care.

Objective: The hospital course for pediatric coarctation repair has not been described. We had 4 aims: (1) to determine the influence of age, anatomy, and type of repair on aortic crossclamp time, (2) to determine the impact of age or aortic crossclamp time on postoperative morbidity, (3) to describe current antihypertensive strategies, and (4) to describe antihypertensive medications at hospital discharge., Methods: Data were obtained from a prospective randomized multicenter esmolol safety and efficacy trial. The study included patients who were scheduled for a coarctation repair receiving esmolol as their first-line antihypertensive medication in the operating room (n = 118; weight > or = 2.5 kg and age < 6 years)., Results: (1) Patient age and type of coarctation did not affect the aortic crossclamp time. (2) Younger age, but not aortic crossclamp time, was associated with a significantly longer time to extubation and longer hospital length of stay. (3) A combination of esmolol and sodium nitroprusside (Nipride, Roche, Basel, Switzerland) provided excellent early blood pressure control. (4) At discharge, 64% of patients were receiving antihypertensive medications. Older patients were more likely to be discharged with antihypertensive medication (91% of patients aged 2-6 years, P < .0002)., Conclusion: The study describes a multi-institutional approach to the repair of isolated coarctation in infants and children. Patients repaired by end-to-end anastomosis had shorter aortic crossclamp time, younger patients had longer hospital length of stay, a majority of patients had sodium nitroprusside (Nipride) added to esmolol for early blood pressure control, and older patients were more likely to be discharged with antihypertensive medication.

Objective: The risk of death during the interstage period remains high after stage 1 reconstruction for single ventricle lesions, despite improved surgical results. The purpose of this study is to identify risk factors for interstage death and to describe the events leading to interstage death., Methods: A nested case-control study was conducted of 368 patients who underwent stage 1 reconstruction at a single center between January 1998 and April 2005., Results: Among the 313 (85%) hospital survivors, there were 33 (10.5%) interstage deaths. Cases more frequently presented with intact or restrictive atrial septum (9 [27%] vs 4 [4%]; P < .001), were older at the time of surgery (5 [2-40] vs 3 [1-42] days; P = .005), had more postoperative arrhythmias (12 [36%] vs 15 [15%]; P = .01), and a higher incidence of airway or respiratory complications (12 [36%] vs 19 [19%]; P = .04). By multivariate analysis, only intact atrial septum (odds ratio 7.6; 95% confidence intervals 1.9-29.6; P = .003) and age at operation greater than 7 days (odds ratio 3.8; 95% confidence intervals 1.3-11.2; P = .017) were predictors of interstage death., Conclusions: The presence of intact atrial septum and older age at the time of surgery are associated with a higher risk of interstage death. In addition, postoperative arrhythmia and airway complications are associated with a higher risk of interstage death in univariate analysis. The results of this study provide a focus for interstage monitoring and risk stratification of these high-risk infants, which may improve overall survival.

Background: Hyperglycemia has been associated with worse outcome after traumatic brain injury and cardiac surgery in adults. It is not known whether postoperative hyperglycemia results in worse neurodevelopmental outcome after infant cardiac surgery., Methods: Secondary analysis of postoperative glucose levels was performed in infants younger than 6 months of age enrolled in a prospective study of genetic polymorphisms and neurodevelopmental outcomes who were undergoing repair of two-ventricle cardiac defects. Neurodevelopmental outcomes at 1 year of age were assessed with the Bayley Scales of Infant Development-II, yielding two indices: Mental Developmental Index and Psychomotor Developmental Index., Results: Surgical repair was performed in 247 infants with 1 in-hospital and 3 late deaths. Neurodevelopmental evaluation was performed in 188 of 243 (77%) survivors. Glucose levels at cardiac intensive care unit admission and during the first 48 postoperative hours were available for 180 of 188 patients. Mean admission glucose was 328 +/- 106 mg/dL; maximum glucose was 340 +/- 109 mg/dL. At least one glucose was greater than 200 mg/dL in 160 of 180 patients, and 49 of 180 patients (27%) had a glucose greater than 400 mg/dL. Only 1 patient had a glucose less than 50 mg/dL. Female sex (p = 0.02), but no other patient or operative variable, was associated with higher glucose levels. Mean Mental Developmental Index and Psychomotor Developmental Index were 90.6 +/- 14.9 and 81.6 +/- 17.2, respectively. Hyperglycemia was not associated with lower Mental Developmental Index and Psychomotor Developmental Index scores for the entire cohort or for neonates alone., Conclusions: Hyperglycemia is common early after infant cardiac surgery, but is not associated with worse neurodevelopmental outcome at 1 year of age.

Background: Catheter-associated bloodstream infections (CABSI) are among the most common and serious adverse events experienced by critically ill children. Randomized trials have demonstrated that the use of central venous catheters (CVC) coated with antiseptic solutions reduces rates of CABSI in adult patients; however, their efficacy in children has not been evaluated., Objective: To compare the incidence of CABSI, rate of complications, and microbiology of infection in critically ill children treated with antibiotic-coated or noncoated CVC (NC-CVC)., Methods: A prospective observational trial was conducted in the pediatric intensive care unit (PICU) during a 13-month period. A minocycline-rifampin-coated CVC (MR-CVC) or NC-CVC was placed by PICU physicians who nonpreferentially selected CVC type., Results: We studied the outcomes associated with the first CVC placed in 225 patients, including 69 MR-CVC and 156 NC-CVC. Patients who received MR-CVC, as compared with NC-CVC, were similar in gender, age, and severity of illness at time of PICU admission. The incidence density of CABSI did not vary by catheter type [MR-CVC: 7.53 per 1000 catheter-days (95% confidence interval 2.05-19.17); NC-CVC: 8.64 CABSI per 1000 catheter-days (95% confidence interval 3.74-16.96)]. However, the median time to infection in children with MR-CVC was 3-fold longer than in children with NC-CVC [18 versus 5 days (P = 0.053)]. No difference was seen in the incidence of complications, including thrombosis and catheter site reaction, between MR- and NC-CVC. No significant difference was observed in the types of organisms recovered from patients with MR- and NC-CVC., Conclusions: The use of MR-CVC significantly delayed the onset of CABSI in PICU patients. Larger, randomized trials are needed to better define potential differences in the incidence of CABSI, rate of complications, and microbiology of infection among pediatric patients treated with antiseptic-coated CVC and NC-CVC.

Neurologic morbidity has been identified as increasingly problematic in neonates with congenital heart disease as surgical mortality rates have improved. The presence of "congenital brain disease" in patients with congenital heart disease represents a challenge in improving long-term neurologic outcomes. Mechanisms of central nervous system injury in infants undergoing cardiac surgery include hypoxia-ischemia, emboli, reactive oxygen species, and inflammatory microvasculopathy. Preoperatively, the primary focus is on preventing hypoxic-ischemic injury and thromboembolic insults. Modifiable intraoperative factors associated with central nervous system injury include, but are not limited to, pH management, hematocrit during cardiopulmonary bypass, regional cerebral perfusion, and the use of deep hypothermic circulatory arrest. Postoperatively, secondary neurologic injury may be related to post-cardiopulmonary bypass alterations in cerebral autoregulation and additional hypoxic-ischemic insult, seizures, or other issues associated with prolonged intensive care unit stay. In addition to prenatal and modifiable perioperative factors, genetic and environmental factors are known to be important. Unfortunately, modifiable perioperative factors may explain less of the variability in long-term outcomes than do patient-specific factors.

Objective: We compare the hemodynamics and perioperative course of shunt type in hypoplastic left heart syndrome at the time of stage 2 reconstruction and longer-term survival., Methods: We retrospectively reviewed the echocardiograms, catheterizations, and hospital records of all patients who had a stage 1 reconstruction between January 2002 and May 2005 and performed a cross-sectional analysis of hospital survivors., Results: One hundred seventy-six patients with hypoplastic left heart syndrome and variants underwent a stage 1 reconstruction with either a right ventricle-pulmonary artery conduit (n = 62) or a modified Blalock-Taussig shunt (n = 114). The median duration of follow-up is 29.1 months (range, 0-57 months). By means of Kaplan-Meier analysis, there is no difference in survival at 3 years (right ventricle-pulmonary artery conduit: 73% [95% confidence limit, 59%-83%] vs modified Blalock-Taussig shunt: 69% [95% confidence limit, 59%-77%]; P = .6). One hundred twenty-four patients have undergone stage 2 reconstruction (78 modified Blalock-Taussig shunts and 46 right ventricle-pulmonary artery conduits). At the time of the stage 2 reconstruction, patients with right ventricle-pulmonary artery conduits were younger (153 days [range, 108-340 days]; modified Blalock-Taussig shunt, 176 days [range, 80-318 days]; P = .03), had lower systemic oxygen saturation (73% [range, 58%-85%] vs 77% [range, 57%-89%], P < .01), and had higher preoperative hemoglobin levels (15.8 g/dL [range, 13-21 g/dL] vs 14.8 g/dL [range, 12-19 g/dL], P < .01) compared with those of the modified Blalock-Taussig shunt group. By means of echocardiographic evaluation, there was a higher incidence of qualitative ventricular dysfunction in patients with right ventricle-pulmonary artery conduits (14/46 [31%] vs 9/73 [12%], P = .02). However, no difference was observed in common atrial pressure or the arteriovenous oxygen difference., Conclusion: Interim analyses suggest no advantage of one shunt type over another. This report raises concern of late ventricular dysfunction and outcome in patients with a right ventricle-pulmonary artery conduit.

Background: Mediastinitis is a devastating complication of pediatric cardiothoracic surgery. However, risk factors for the development of mediastinitis are poorly characterized. The objective of this study was to identify risk factors for mediastinitis in a cohort of children undergoing cardiothoracic surgery at a tertiary care children's hospital., Methods: This case-control study included patients who underwent median sternotomy between January 1, 1995 and December 31, 2003. Univariate analyses, logistic regression, and multinomial regression were performed to determine the association between potential risk factors and the development of mediastinitis., Results: Forty-three patients with mediastinitis and 184 patients without mediastinitis were included. One hundred and twelve (49%) patients were female. The median patient age was 128 days (interquartile range: 7 days-2.0 years). A known or possible genetic syndrome was present in 53 (24%) patients. The following factors were associated with the development of mediastinitis: presence of a known or possible genetic syndrome (adjusted odds ratio, OR: 4.5; 95% confidence interval, CI: 1.8-11.4); American Society of Anesthesiologists score >3 (adjusted OR: 3.4; 95% CI: 1.1-10.3); and presence of intracardiac pacing wires for >3 days (adjusted OR: 15.8; 95% CI: 2.0-127.2)., Conclusions: The presence of a known or possible genetic syndrome, American Society of Anesthesiologists score >3, and the presence of intracardiac pacing wires for >3 days were each associated with the development of mediastinitis in children after median sternotomy.

Objectives: Postoperative bloodstream infections are a major source of morbidity and increased health care costs. In adults, mediastinitis has been described as a risk factor for bloodstream infections. The objectives of this retrospective cohort study were to determine the incidence and to identify risk factors for postoperative bloodstream infections among children after median sternotomy in an urban tertiary care children's hospital., Methods: For this study, 192 patients were randomly selected from among all patients undergoing median sternotomy between January 1, 1995, and December 31, 2003., Results: Ninety-eight (51%) of the 192 eligible patients were male. The median patient age was 5.4 months (interquartile range: 1 day-41.5 years). Bloodstream infections occurred in 12 (6.3%; 95% confidence interval [CI]: 3.3%-10.7%) patients within the first 30 days after median sternotomy. Bloodstream infections developed a median of 11 days (range: 3-29 days) after median sternotomy. Gram-negative bacilli caused 6 (50%) of the 12 bloodstream infections. Specific causes of bloodstream infections included Pseudomonas aeruginosa (n = 3), coagulase-negative staphylococci (n = 3), Pseudomonas fluorescens-putida (n = 2), Staphylococcus aureus (n = 2), Serratia marcescens (n = 1), and Candida albicans (n = 1). Multivariable analysis revealed that the development of mediastinitis (odds ratio [OR], 28.16; 95% CI, 3.37-235.22) and the requirement for postoperative extracorporeal membrane oxygenation (OR, 12.52; 95% CI, 2.99-52.41) were associated with bloodstream infections after median sternotomy., Conclusions: Postoperative bloodstream infections occurred in 6.3% of children undergoing median sternotomy. Postoperative mediastinitis and the requirement for extracorporeal membrane oxygenation were risk factors for bloodstream infections after median sternotomy. These findings warrant exploration in a larger, multicenter study.

Object: Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring are fundamental to the management of severe traumatic brain injury (TBI). In adults, brain tissue oxygen monitoring (specifically PO2) and treatment have been shown to be safe additions to conventional neurocritical care and are associated with improved outcome. Brain tissue oxygen monitoring, however, has not been described in pediatric patients with TBI. In this report, the authors present preliminary experience with the use of ICP and PO2 monitoring in this population., Methods: Pediatric patients (age <18 years) with severe TBI (Glasgow Coma Scale score <8) admitted to a Level 1 trauma center who underwent ICP and PO2 monitoring were evaluated. Therapy was directed at maintaining ICP below 20 mm Hg and age-appropriate CPP (> or =40 mm Hg). Data obtained in six patients (two girls and four boys ranging in age from 6-16 years) were analyzed. Brain tissue oxygen levels were significantly higher (p < 0.01) at an ICP of less than 20 mm Hg (PO2 29.29 +/- 7.17 mm Hg) than at an ICP of greater than or equal to 20 mm Hg (PO2 22.83 +/- 13.85 mm Hg). Significant differences (p < 0.01) were also measured when CPP was less than 40 mm Hg (PO2 2.53 +/- 7.98 mm Hg) and greater than or equal to 40 mm Hg (PO2 28.97 +/- 7.85 mm Hg)., Conclusions: Brain tissue oxygen monitoring may be a safe and useful addition to ICP monitoring in the treatment of pediatric patients with severe TBI.

Background: Recent reports advocate that a right ventricular to pulmonary artery (RV-PA) conduit improves outcome after the stage I reconstruction., Methods: We retrospectively compared the outcomes of all neonates who underwent a stage I reconstruction between January 1, 2002, and October 1, 2004, with use of the RV-PA conduit and modified Blalock-Taussig shunt (mBTS) interspersed over this time period., Results: In all, 149 infants underwent a stage I reconstruction (95 mBTS, 54 RV-PA) for hypoplastic left heart syndrome (HLHS) or variants. There was a preference for the RV-PA conduit in patients with aortic atresia (mBTS 30% versus RV-PA 67%, p < 0.01). There was no difference in surgical mortality (mBTS 14% versus RV-PA 17%, p = 0.67), time to extubation (mBTS 4.5 +/- 4.8 days versus RV-PA 3.9 +/- 3.5 days, p = 0.47), or length of hospital stay (mBTS 25 +/- 29 days versus RV-PA 21 +/- 23 days, p = 0.52). There was an increased incidence of shunt reinterventions in the patients with the RV-PA conduit (mBTS 17% versus RV-PA 32%, p = 0.04). Patients with RV-PA conduit returned earlier for stage II reconstruction (mBTS 6.5 +/- 2.5 months versus RV-PA 5.6 +/- 1.7 months, p = 0.05). There was no difference in overall mortality (mBTS 32% versus RV-PA 30%, p = 0.45) with a median duration of follow-up of 18 +/- 8 months., Conclusions: Comparing shunt strategies (mBTS versus RV-PA) over the same time period, we found no difference in outcome. These data support the need for a larger prospective, randomized trial.