Joan M. LaRovere

Prenatal screening for major congenital heart disease: Assessing performance by combining national cardiac audit with maternity data

Objective Determine maternity hospital and lesion-specific prenatal detection rates of major congenital heart disease (mCHD) for hospitals referring prenatally and postnatally to one Congenital Cardiac Centre, and assess interhospital relative performance (relative risk, RR). Methods We manually linked maternity data (3 hospitals prospectively and another 16 retrospectively) with admissions, fetal diagnostic and surgical cardiac data from one Congenital Cardiac Centre. This Centre submits verified information to National Institute for Cardiovascular Outcomes Research (NICOR-Congenital), which publishes aggregate antenatal diagnosis data from infant surgical procedures. We included 120u2005198 unselected women screened prospectively over 11u2005years in 3 maternity hospitals (A, B, C). Hospital A: colocated with fetal medicine, proactive superintendent, on-site training, case-review and audit, hospital B: on-site training, proactive superintendent, monthly telemedicine clinics, and hospital C: sonographers supported by local obstetrician. We then studied 321 infants undergoing surgery for complete transposition (transposition of the great arteries (TGA), n=157) and isolated aortic coarctation (CoA, n=164) screened in hospitals A, B, C prospectively, and 16 hospitals retrospectively. Results 385 mCHD recorded prospectively from 120u2005198 (3.2/1000) screened women in 3 hospitals. Interhospital relative performance (RR) in Hospital A:1.68 (1.4 to 2.0), B:0.70 (0.54 to 0.91), C:0.65 (0.5 to 0.8). Standardised prenatal detection rates (funnel plots) demonstrating inter-hospital variation across 19 hospitals for TGA (37%, 0.00 to 0.81) and CoA (34%, 0.00 to 1.06). Conclusions Manually linking data sources produced hospital-specific and lesion-specific prenatal mCHD detection rates. More granular, rather than aggregate, data provides meaningful feedback to improve screening performance. Automatic maternal and infant record linkage on a national scale, requires verified, prospective maternity audit and integration of health information systems.

Early postoperative outcomes following surgical repair of complete atrioventricular septal defects: is down syndrome a risk factor?

Objective: To evaluate the impact of Down syndrome on the early postoperative outcomes of children undergoing complete atrioventricular septal defect repair. Design: Retrospective cohort study. Setting: Single tertiary pediatric cardiac center. Patients: All children admitted to PICU following biventricular surgical repair of complete atrioventricular septal defect from January 2004 to December 2009. Interventions: None. Measurements and Main Results: A total of 107 children, 67 with Down syndrome, were included. Children with Down syndrome were operated earlier: 4 months (interquartile range, 3.5–6.6) versus 5.7 months (3–8.4) for Down syndrome and non-Down syndrome groups, respectively (p < 0.01). There was no early postoperative mortality. There was no significant difference in the prevalence of dysplastic atrioventricular valve between the two groups. Two children (2.9%) from Down syndrome and three children (7.5%) from non-Down syndrome group required early reoperation (p = 0.3). Junctional ectopic tachycardia was the most common arrhythmia, and the prevalence of junctional ectopic tachycardia was similar between the two groups (9% and 10% in Down syndrome and non-Down syndrome, respectively, p = 1). One patient from each group required insertion of permanent pacemaker for complete heart block. Children with Down syndrome had significantly higher prevalence of noncardiac complications, that is, pneumothorax, pleural effusions, and infections (p < 0.01), than children without Down syndrome. There was a trend for longer duration of mechanical ventilation in children with Down syndrome (41u2009hr [20–61 hr] vs 27.5u2009hr [15–62 hr], p = 0.2). However, there was no difference in duration of PICU stay between the two groups (2 d [1.3–3 d] vs 2 d [1–3 d], p = 0.9, respectively). Conclusions: In our study, we found no difference in the prevalence of atrioventricular valve dysplasia between children with and without Down syndrome undergoing complete atrioventricular septal defect repair. This finding contrasts with previously published data, and further confirmatory studies are required. Although clinical outcomes were similar, children with Down syndrome had a significantly higher prevalence of noncardiac complications in the early postoperative period than children without Down syndrome.

Non-invasive ventilation for children with acute respiratory failure in the developing world: Literature review and an implementation example

Over 2 million children die of acute respiratory infection every year, with around 98% of these deaths occurring in developing countries. Depending upon the clinical status of the patient, supplemental oxygen is usually the first line therapy. However this often proves inadequate for acute respiratory failure (ARF), in which case intubation and mechanical positive pressure ventilation are required. Adult intensive care successfully introduced non-invasive positive pressure ventilation (NIPPV) to treat ARF over a decade ago. This experience, coupled with the use of NIPPV in children with chronic respiratory insufficiency, has led to increasing use of NIPPV to treat ARF in paediatric populations. NIPPV can have similar or improved outcomes to IPPV, but with fewer complications. However there are no controlled trials of its use in children, and most data come from observational studies and retrospective reviews. In a developing world setting, where mortality from ARF is high and the risks of intubation are great and often not feasible, NIPPV can be a simple and cost-effective way to treat these patients. Its implementation in rural Northern Ghana shows NIPPV for ARF can be delivered safely with minimal training, and appears to impact significantly on mortality in those under 5 years.

Mesenteric near-infrared spectroscopy and risk of gastrointestinal complications in infants undergoing surgery for congenital heart disease

We hypothesised that lower mesenteric near-infrared spectroscopy values would be associated with a greater incidence of gastrointestinal complications in children weighing <10 kg who were recovering from cardiac surgery. We evaluated mesenteric near-infrared spectroscopy, central venous oxygen saturation, and arterial blood gases for 48 hours post-operatively. Enteral feeding intake, gastrointestinal complications, and markers of organ dysfunction were monitored for 7 days. A total of 50 children, with median age of 16.7 (3.2-31.6) weeks, were studied. On admission, the average mesenteric near-infrared spectroscopy value was 71±18%, and the systemic oxygen saturation was 93±7.5%. Lower admission mesenteric near-infrared spectroscopy correlated with longer time to establish enteral feeds (r=-0.58, p<0.01) and shorter duration of feeds at 7 days (r=0.48, p<0.01). Children with gastrointestinal complications had significantly lower admission mesenteric near-infrared spectroscopy (58±18% versus 73±17%, p=0.01) and higher mesenteric arteriovenous difference of oxygen at admission [39 (23-47) % versus 19 (4-27) %, p=0.02]. Based on multiple logistic regression, admission mesenteric near-infrared spectroscopy was independently associated with gastrointestinal complications (Odds ratio, 0.95; 95% confidence interval, 0.93-0.97; p=0.03). Admission mesenteric near-infrared spectroscopy showed an area under the receiver operating characteristic curve of 0.76 to identify children who developed gastrointestinal complications, with a suggested cut-off value of 72% (78% sensitivity, 68% specificity). In this pilot study, we conclude that admission mesenteric near-infrared spectroscopy is associated with gastrointestinal complications and enteral feeding tolerance in children after cardiac surgery.

S76 Non-invasive positive pressure ventilation to reduce childhood mortality from acute respiratory failure in rural ghana

Introduction and Objectives Acute respiratory failure (ARF) is a major cause of mortality in the developing world, exacerbated by resource limitation. Non-invasive positive pressure ventilation (NIPPV) is a potential simple way to reduce mortality, and whilst established in adults, evidence in children is lacking. Methods The study was conducted in Tumu District Hospital in Northern Ghana, which serves a catchment of 56,000 and has an under-5 Mortality of 142 per 1000 live births. Two Nippy Junior paediatric pressure controlled portable ventilators, chosen for ease of use and robustness, were used along with finger monitors to measure oxygen saturation and heart rate. Training of nurses, the nurse anaesthetist and the doctor was achieved with interactive lectures, hands-on workshops and competency assessment over 3 days in November 2011 and April 2012. Laminated guides attached to each machine outlined criteria to commence, escalate and wean NIPPV. Criteria for commencing NIPPV were based on respiratory rate, oxygen saturation, intercostal recession and expiratory grunting. Results In the initial 4 months of NIPPV use, 657 children under 5 were admitted with 11 deaths, of whom 84 received NIPPV with 3 deaths. In the subsequent 9 months, NIPPV was used in 46 children and 11 adults, with no deaths. Of 140 patients ventilated in 2012, 106 (76%) were under five and 60 (43%) under the age of two. There were 2 deaths from malaria/sepsis with an overall mortality of 1.4% (1.9% <5 years). Primary diagnoses by age as best available are displayed in figure 1. No complications were reported apart from discomfort in some patients. Patients were ventilated for shorter periods than usual in the developed world. Ventilation times were notably shorter in malaria patients. Those with respiratory tract infections and pneumonia tend to be ventilated longer and were often more comfortable with ventilation for longer periods at a time. Abstract S76 Figure 1. Conclusions This feasibility study shows NIPPV for ARF in children in a rural setting can be delivered safely with minimal training and appears to impact significantly on mortality in those under 5.

Risky business: human factors in critical care.

Remarkable achievements have occurred in pediatric cardiac critical care over the past two decades. The specialty has become well defined and extremely resource intense. A great deal of focus has been centered on optimizing patient outcomes, particularly mortality and early morbidity, and this has been achieved through a focused and multidisciplinary approach to management. Delivering high-quality and safe care is our goal, and during the Risky Business symposium and simulation sessions at the Eighth International Conference of the Pediatric Cardiac Intensive Care Society in Miami, December 2010, human factors, systems analysis, team training, and lessons learned from malpractice claims were presented.