In the vast majority of Children's Hospitals, the critically ill patient can be found in one of three locations: the PICU, the neonatal ICU, and the cardiac ICU. Training, certification, and maintenance of certification for neonatology and critical care medicine are over seen by the Accreditation Council for Graduate Medical Education and American Board of Pediatrics. There is no standardization of training or oversight of certification and maintenance of certification for pediatric cardiac critical care.The curricula from the twenty 4th year pediatric cardiac critical care training programs were collated, along with the learning objectives from the Pediatric Cardiac Intensive Care Society published "Curriculum for Pediatric Cardiac Critical Care Medicine."This initiative is endorsed by the Pediatric Cardiac Intensive Care Society as a first step toward Accreditation Council for Graduate Medical Education oversight of training and American Board of Pediatrics oversight of maintenance of certification.A taskforce was established of cardiac intensivists, including the directors of all 4th year pediatric cardiac critical care training programs.Using modified Delphi methodology, learning objectives, rotational requirements, and institutional requirements for providing training were developed.In the current era of increasing specialized care in pediatric cardiac critical care, standardized training for pediatric cardiac critical care is paramount to optimizing outcomes.
Introduction: Thrombotic complications cause significant morbidity and mortality among pediatric patients on ECMO. Due to inflammatory cascades on initial circuit exposure, anticoagulation factors immediately after cannulation may be critical in preventing early thrombosis. This study examined the relationship between anticoagulation characteristics and clinical predictors in the first 24 hours of ECMO and the development of clinically significant thrombosis within the first 48 hours of ECMO. Methods: A retrospective, single center study was conducted of all ECMO patients admitted to the pediatric intensive care unit at a large quaternary academic children’s hospital between 1/1/2014-3/31/2021. Variables were collected from the electronic medical record, including demographic and clinical features, ECMO course characteristics, and characteristics (heparin use) and laboratory measures of anticoagulation [activated clotting time (ACT), partial thromboplastin time (PTT), and anti-factor Xa (anti-Xa)]. Lab values were categorized as subtherapeutic, therapeutic, or supratherapeutic for analysis. The primary outcome was clinically significant patient or circuit thrombosis in the first 48 hours of ECMO. Data are shown as median (IQR) and analyzed by Wilcoxon Rank-Sum and regression analysis. Results: Among 71 patients with 72 ECMO runs, there were 40 thrombotic events; 13 occurred in the first 48 hours. The median (IQR) percent of subtherapeutic ACT (44%, 18.2–71.4), PTT (42.9%, 15.3–71.4), and anti-Xa (100%, 50–100) values in the first 24hrs of ECMO had no relationship to the development of thrombosis within the first 48 hours of ECMO support. In multivariate regression analysis, time to initiation of a heparin infusion after cannulation (OR 1.38, 95% CI 1.01–1.87) and pre-ECMO PELOD-2 score (OR 0.74, 95% CI 0.56–0.96) were significantly associated with odds of having a thrombotic complication in the first 48 hours on ECMO. Conclusions: Patients with delayed initiation of systemic anticoagulation with a heparin infusion and those with lower illness severity scores at the time of cannulation may be particularly susceptible to clinically significant thrombotic complications within the first 48 hours of ECMO support. Further study is needed to explore this relationship.
