To describe the epidemiology of noninvasive ventilation therapy for patients admitted to pediatric cardiac ICUs and to assess practice variation across hospitals.Retrospective cohort study using prospectively collected clinical registry data.Pediatric Cardiac Critical Care Consortium clinical registry.Patients admitted to cardiac ICUs at PC4 hospitals.None.We analyzed all cardiac ICU encounters that included any respiratory support from October 2013 to December 2015. Noninvasive ventilation therapy included high flow nasal cannula and positive airway pressure support. We compared patient and, when relevant, perioperative characteristics of those receiving noninvasive ventilation to all others. Subgroup analysis was performed on neonates and infants undergoing major cardiovascular surgery. To examine duration of respiratory support, we created a casemix-adjustment model and calculated adjusted mean durations of total respiratory support (mechanical ventilation + noninvasive ventilation), mechanical ventilation, and noninvasive ventilation. We compared adjusted duration of support across hospitals. The cohort included 8,940 encounters from 15 hospitals: 3,950 (44%) received noninvasive ventilation and 72% were neonates and infants. Medical encounters were more likely to include noninvasive ventilation than surgical. In surgical neonates and infants, 2,032 (55%) received postoperative noninvasive ventilation. Neonates, extracardiac anomalies, single ventricle, procedure complexity, preoperative respiratory support, mechanical ventilation duration, and postoperative disease severity were associated with noninvasive ventilation therapy (p < 0.001 for all). Across hospitals, noninvasive ventilation use ranged from 32% to 65%, and adjusted mean noninvasive ventilation duration ranged from 1 to 4 days (3-d observed mean). Duration of total adjusted respiratory support was more strongly correlated with duration of mechanical ventilation compared with noninvasive ventilation (Pearson r = 0.93 vs 0.71, respectively).Noninvasive ventilation use is common in cardiac ICUs, especially in patients admitted for medical conditions, infants, and those undergoing high complexity surgery. We observed wide variation in noninvasive ventilation use across hospitals, though the primary driver of total respiratory support time seems to be duration of mechanical ventilation.
Background: Newborns with d-transposition of the great arteries (d-TGA) often require an urgent balloon atrial septostomy (BAS) immediately after birth, which can be challenging to predict. As such, cardiac centers, especially those without in-house delivery, should plan for immediate transport and cardiac intervention. The objective of this study was to evaluate the impact of risk stratification on both transport times to the cardiac intensive care unit (CICU) and to BAS in the d-TGA population. Methods: A retrospective analysis was performed on all fetuses with d-TGA and an intact ventricular septum born between 1/1/2013 and 12/31/2023. Fetuses born before 2018 were not risk stratified or assigned a level of care (LOC) assignment. Fetuses born after 2018 were assigned either a moderate risk of hemodynamic instability (LOC 3) or high risk of hemodynamic instability (LOC 4), based on findings on fetal echocardiography (FE) associated with increased risk for urgent BAS. Primary outcomes were times from birth to CICU arrival and from birth to BAS. A BAS was considered urgent if completed within 2 hours of CICU arrival. A BAS was excluded if performed greater than 48 hours after birth. Statistical analyses compared time-based outcomes among pre-LOC and post-LOC fetuses (stratified as either LOC 3 or 4). Results: A total of 81 newborns with a prenatal diagnosis of d-TGA were analyzed. Fetuses assigned an LOC had a lower time between birth and CICU arrival compared to fetuses with d-TGA who were not risk stratified (p=0.012) (Table 1). There were no differences in times from birth to BAS or from CICU arrival to BAS for pre- or post-LOC groups. Conclusion: Implementation of risk stratification for d-TGA fetuses can help decrease time between birth and arrival to the CICU. Risk stratification and appropriate delivery planning should be considered, especially at centers without in-house delivery. Although risk stratification alone does not shorten time to cardiac intervention, further research is needed to determine if other prenatal characteristics may predict which patients will require an urgent BAS.
Current risk adjustment models for congenital heart surgery do not fully incorporate multiple factors unique to neonates such as granular gestational age (GA) and birth weight (BW) z score data. This study sought to develop a Neonatal Risk Adjustment Model for congenital heart surgery to address these deficiencies.Cohort study of neonates undergoing cardiothoracic surgery during the neonatal period captured in the Pediatric Cardiac Critical Care Consortium database between 2014 and 2020. Candidate predictors were included in the model if they were associated with mortality in the univariate analyses. GA and BW z score were both added as multicategory variables. Mortality probabilities were predicted for different GA and BW z scores while keeping all other variables at their mean value.The C statistic for the mortality model was 0.8097 (95% confidence interval, 0.7942-0.8255) with excellent calibration. Mortality prediction for a neonate at 40 weeks GA and a BW z score 0 to 1 was 3.5% versus 9.8% for the same neonate at 37 weeks GA and a BW z score -2 to -1. For preterm infants the mortality prediction at 34 to 36 weeks with a BW z score 0 to 1 was 10.6%, whereas it was 36.1% for the same infant at <32 weeks with a BW z score of -2 to -1.This Neonatal Risk Adjustment Model incorporates more granular data on GA and adds the novel risk factor BW z score. These 2 factors refine mortality predictions compared with traditional risk models. It may be used to compare outcomes across centers for the neonatal population.
1Georgia Institute of Technology, Atlanta, GA 2Children’s Healthcare of Atlanta Emory University, Atlanta, GA 3Emory University, Children’s Healthcare of Atlanta At Egleston, Atlanta, GA
There is an ongoing need for a method of obtaining long-term venous access in critically ill pediatric patients that can be completed at the bedside and results in a durable, highly functional device. We designed a novel technique for tunneled femoral access to address this need. Herein, we describe the procedure and review the outcomes at our institution.A single-center retrospective chart review identifying patients who underwent tunneled femoral central venous catheter (tfCVC) placement between 2017 and 2021 using a two-puncture technique developed by our team.Academic, Quaternary Children's Hospital with a dedicated pediatric cardiac ICU (CICU).Patients in our pediatric CICU who underwent this procedure.Tunneled femoral central line placement.One hundred eighty-two encounters were identified in 161 patients. The median age and weight at the time of catheter placement was 22 days and 3.2 kg. The median duration of the line was 22 days. The central line-associated bloodstream infection (CLABSI) rate was 0.75 per 1,000-line days. The prevalence rate of thrombi necessitating pharmacologic treatment was 2.0 thrombi per 1,000-line days. There was no significant difference in CLABSI rate per 1,000-line days between the tfCVC and nontunneled peripherally inserted central catheters placed over the same period in a similar population (-0.40 [95% CI, -1.61 to 0.82; p = 0.52]) and no difference in thrombus rates per 1,000-line days (1.37 [95% CI, -0.15 to 2.89; p = 0.081]).tfCVCs can be placed by the intensivist team using a two-puncture technique at the bedside with a high-rate of procedural success and low rate of complications. Advantages of this novel technique of obtaining vascular access include a low rate of CLABSIs, the ability to place it at the bedside, and preservation of the upper extremity vasculature.
A session dedicated to heterotaxy syndrome was included in the program of the Tenth International Conference of the Pediatric Cardiac Intensive Care Society in Miami, Florida in December 2014. An invited panel of experts reviewed the anatomic considerations, surgical considerations, noncardiac issues, and long-term outcomes in this challenging group of patients. The presentations, summarized in this article, reflect the current approach to this complex multiorgan syndrome and highlight future areas of clinical interest and research.
