Darren Klugman

Demographics, Trends, and Outcomes in Pediatric Acute Myocarditis in the United States, 2006 to 2011

Background—There is a lack of clear diagnostic and management guidelines for acute myocarditis in the pediatric population. We used a multi-institutional database to characterize demographics, practice variability, and outcomes in this population. Methods and Results—Patients with acute myocarditis (n=514) were identified from April 2006 to March 2011 using the Pediatric Health Information System database, and regional variations in management and outcomes were analyzed. Ninety-seven patients (18.9%) received extracorporeal membrane oxygenation, 22 (4.3%) received ventricular assist device, 21 (4.1%) received heart transplantation, and 37 (7.2%) died. Of the 104 patients who received extracorporeal membrane oxygenation or ventricular assist device, 17 (16.3%) had heart transplantation, 25 (24%) died, and 62 (59.6%) showed recovery of myocardial function. There was a decrease in the use of endomyocardial biopsy (P=0.03) and an increase in the use of magnetic resonance imaging (P<0.01) over the study period. Although the use of medications and procedures varied between different regions, the occurrence of death or heart transplantation showed no significant regional associations. The use of extracorporeal membrane oxygenation (odds ratio, 5.8; 95% confidence interval, 2.9–11.4; P<0.01), ventricular assist device (odds ratio, 8.2; 95% confidence interval, 2.7–24.9; P<0.01), and vasoactive medications (odds ratio, 5.7; 95% confidence interval, 1.2–26.1; P=0.03) was independently associated with death/transplantation. Conclusions—There is significant temporal and regional variation in the diagnostic modalities and management used for pediatric myocarditis, which continues to have high morbidity and mortality. Extracorporeal membrane oxygenation, ventricular assist device, and vasoactive medications are independently associated with increased mortality/transplantation.

Clinical Epidemiology of Extubation Failure in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium

Objective: To describe the clinical epidemiology of extubation failure in a multicenter cohort of patients treated in pediatric cardiac ICUs. Design: Retrospective cohort study using prospectively collected clinical registry data. Setting: Pediatric Cardiac Critical Care Consortium registry. Patients: All patients admitted to the CICU at Pediatric Cardiac Critical Care Consortium hospitals. Interventions: None. Measurements and Main Results: Analysis of all mechanical ventilation episodes in the registry from October 1, 2013, to July 31, 2014. The primary outcome of extubation failure was reintubation less than 48 hours after planned extubation. Repeated-measures analysis using generalized estimating equations to account for within patient and center correlation was performed to identify risk factors for extubation failure. Adjusted extubation failure rates for each hospital were calculated using logistic regression controlling for patient factors. Of 1,734 mechanical ventilation episodes (1,478 patients at eight hospitals) ending in a planned extubation, there were 100 extubation failures (5.8%). In multivariable analysis, only longer duration of mechanical ventilation was significantly associated with extubation failure (p = 0.01); the failure rate was 4% when ventilated less than 24 hours, 9% after 24 hours, and 13% after 7 days. For 503 patients intubated and extubated in the cardiac operating room, 15 patients (3%) failed extubation within 48 hours (12 within 24 hr). Case-mix-adjusted extubation failure rates ranged from 1.1% to 9.8% across hospitals. Patients failing extubation had greater median cardiac ICU length of stay (15 vs 3 d; p < 0.001) and in-hospital mortality (7.9 vs 1.2%; p < 0.001). Conclusions: Though extubation failure is uncommon overall, there may be opportunities to improve extubation readiness assessment in patients ventilated more than 24 hours. These data suggest that extubation in the operating room after cardiac surgery can be done with a low failure rate. We observed variation in extubation failure rates across hospitals, and future investigation must elucidate the optimal strategies of high-performing centers to reduce ventilation time while limiting extubation failures.

Unplanned Extubations in Children: Impact on Hospital Cost and Length of Stay.

Objective: To determine the attributable hospital cost, both operational and departmental, and length of stay associated with unplanned extubations in children admitted to PICU and cardiac ICU. Design: Retrospective, matched case-control study. Setting: Forty-four-bed PICU and 26-bed cardiac ICU in a 303-bed tertiary care pediatric hospital. Patients: Cases with an unplanned extubation were retrospectively identified from July 2011 to March 2013. Controls were PICU and cardiac ICU patients admitted over the same time period and were matched at a ratio of 2:1 for age and diagnosis. Interventions: None. Measurements and Main Results: Forty-eight unplanned extubations were analyzed. There were no differences in patient demographics between the two groups, except the control group had a higher severity of illness as illustrated by a larger Paediatric Index of Mortality II Risk of Mortality. Median total hospital costs were higher in those patients with unplanned extubations as compared with controls (

Echocardiography as a hemodynamic monitor in critically ill children

101,310 vs

Acute harm: unplanned extubations and cardiopulmonary resuscitation in children and neonates

64,618; p < 0.001). Patients with an unplanned extubation had longer median ICU length of stay (10 d vs 4.5 d; p < 0.001) and hospital length of stay (16.5 d vs 10 d, p < 0.001). Conclusion: Pediatric patients with unplanned extubations have an associated increase in hospital costs (

Off-label drug use in a single-center pediatric cardiac intensive care unit.

36,692/case) and length of stay (6.5 d/case) as compared with age and diagnosis-matched controls. Further efforts are warranted to establish data-driven benchmarks and establishment of unplanned extubations as a critical metric for ICU quality.

Variation in extubation failure rates after neonatal congenital heart surgery across Pediatric Cardiac Critical Care Consortium hospitals

Echocardiography is a widely used modality to assess myocardial structure and function in pediatric intensive care settings. While the use of echocardiography for diagnostic purposes remains important, its use as a hemodynamic monitoring tool has not been well established. The benefits of echocardiography are in its widespread availability, relative ease of use, and importance in diagnosing structural disease and simple changes in myocardial function. However, echocardiography in pediatric critical care is limited in its use because it requires the acquisition of quality images and the accurate interpretation of the study. To date, the literature on echocardiography in pediatric critical care is limited. The purpose of this review is to examine the scientific evidence for the usefulness of echocardiography as a hemodynamic monitoring tool in pediatric critical care.

Trisomy 9 mosaicism and XX sex reversal.

Dear Editor, Invasive mechanical ventilation is a common therapy used for children and infants in the intensive care unit (ICU). The impact of unplanned extubation (UE) on morbidity and mortality in adults is well described [1, 2]. There remains a paucity of data related to the cardiovascular morbidity associated with UE events in children. Following review and approval by the institutional review board in accordance and compliance with international ethics standards, we performed a retrospective database review of all UE events in patients admitted to the neonatal, pediatric or cardiac ICU at our institution between July 2011 and December 2012. UE was defined as the removal of an endotracheal tube in a mechanically ventilated patient which was not directed or ordered by a licenced independent practitioner. Cardiovascular collapse was defined as the need for cardiopulmonary resuscitation (e.g., external chest compressions) or circulatory dysfunction immediately following the UE event. Patients with tracheostomies were excluded from our analysis. Preliminary data were presented at the Pediatric Academic Societies’ and Asian Society for Pediatric Research Joint Meeting in Denver, Colorado in 2011 [3]. There were 119 UE events involving 95 unique patients, and the UE rate (events/100 ventilator days) was 0.5. Cardiovascular collapse occurred in 24 events (20 %), of which 20 involved initiation of cardiopulmonary resuscitation. Four events were characterized by circulatory dysfunction requiring immediate re-intubation without initiation of cardiopulmonary resuscitation. There was no immediate mortality associated with these events. We compared UE event characteristics stratified by presence or absence of cardiovascular collapse (Table 1). Immediate re-intubation was performed in 75 (63 %) events and was more likely in patients with cardiovascular collapse (p = 0.01). Cardiovascular collapse was more likely in younger patients (p = 0.048). It has been recognized for some time that UE carries with it significant morbidity increasing the risk of nosocomial infection and length of mechanical ventilation and ICU stay [1]. This is the first study that we are aware of that assesses the frequency of cardiovascular morbidity associated with UE in children. While much of the cardiovascular morbidity occurred in our neonatal population, our data suggest that unplanned extubations in critically ill children and neonates can lead to previously unrecognized morbidity. Despite recent advances in cardiopulmonary resuscitation and extracorporeal membrane oxygenation, in-hospital cardiac arrest portends poor outcomes with survival to discharge rates hovering around 25 % [4]. Our study is limited by the lack of long-term followup data to assess the impact of UE on mortality. However, our data do suggest there is potential for increased mortality associated with UE events. In conclusion, the frequency of cardiovascular morbidity in children

Surgical Site Infection After Pediatric Cardiothoracic Surgery.

Background: The frequency of off-label drug use and its association with morbidity and mortality in the cardiac intensive care unit (CICU) has not been previously studied. Methods: Patients less than 18 years of age admitted to the CICU from June to August 2008 were retrospectively identified. Patient demographics were collected for 30 days or until CICU discharge. Off-label drug use was defined as the prescription of a medication that lacked a labeled indication based on patient’s age as reported in the Micromedex drug database and electronic Physician’s Desk Reference. Results: Eighty-two patients were admitted to the CICU during the study period. In all, 40 (46%) patients were male; the median age was 10.6 months. Common diagnoses were left-to-right shunt lesions (20.7%) and single-ventricle lesions (20.7%), with an overall mortality of 2.4%. Of all drugs prescribed, 36% were off-label. In all, 94% of the patients received ≥1 drug off-label. The median number of drugs prescribed off-label was four. Patients receiving more than four off-label medications were younger, had longer CICU lengths of stay (median 9.5 vs 2 days, P < .001), and increased ventilator days (median two vs one day, P < .001). Conclusions: Off-label drug use in the CICU is common. Frequency of use is likely higher in patients with a higher severity of illness. Further safety, efficacy, and pharmaceutical trials are warranted to optimize the use of these drugs to improve outcomes.

National variation in the use of tracheostomy in patients with congenital heart disease

Objective: In a multicenter cohort of neonates recovering from cardiac surgery, we sought to describe the epidemiology of extubation failure and its variability across centers, identify risk factors, and determine its impact on outcomes. Methods: We analyzed prospectively collected clinical registry data on all neonates undergoing cardiac surgery in the Pediatric Cardiac Critical Care Consortium database from October 2013 to July 2015. Extubation failure was defined as reintubation less than 72 hours after the first planned extubation. Risk factors were identified using multivariable logistic regression with generalized estimating equations to account for within‐center correlation. Results: The cohort included 899 neonates from 14 Pediatric Cardiac Critical Care Consortium centers; 14% were premature, 20% had genetic abnormalities, 18% had major extracardiac anomalies, and 74% underwent surgery with cardiopulmonary bypass. Extubation failure occurred in 103 neonates (11%), within 24 hours in 61%. Unadjusted rates of extubation failure ranged from 5% to 22% across centers; this variability was unchanged after adjusting for procedural complexity and airway anomaly. After multivariable analysis, only airway anomaly was identified as an independent risk factor for extubation failure (odds ratio, 3.1; 95% confidence interval, 1.4–6.7; P = .01). Neonates who failed extubation had a greater median postoperative length of stay (33 vs 23 days, P < .001) and in‐hospital mortality (8% vs 2%, P = .002). Conclusions: This multicenter study showed that 11% of neonates recovering from cardiac surgery fail initial postoperative extubation. Only congenital airway anomaly was independently associated with extubation failure. We observed a 4‐fold variation in extubation failure rates across hospitals, suggesting a role for collaborative quality improvement to optimize outcomes.