Kendal M. Endicott

IV Versus Subcutaneous Enoxaparin in Critically Ill Infants and Children: Comparison of Dosing, Anticoagulation Quality, Efficacy, and Safety Outcomes.

Objective: Subcutaneous enoxaparin is the mainstay anticoagulant in critically ill pediatric patients although it poses several challenges in this patient population. Enoxaparin infused IV over 30 minutes represents an attractive alternative, but there is limited experience with this route of administration in children. In this study, we assess dosing, anticoagulation quality, safety, and clinical efficacy of IV enoxaparin compared to subcutaneous enoxaparin in critically ill infants and children. Design: Retrospective single-center study comparing dosing, anticoagulation quality, safety, and clinical efficacy of two different routes of enoxaparin administration (IV vs subcutaneous) in critically ill infants and children. Key outcome measures included dose needed to achieve target antifactor Xa levels, time required to achieve target antifactor Xa levels, proportion of patients achieving target anticoagulation levels on initial dosing, number of dose adjustments, duration spent in the target antifactor Xa range, anticoagulation-related bleeding complications, anticoagulation failure, and radiologic response to anticoagulation. Setting: Tertiary care pediatric hospital. Patients: All children admitted to the cardiac ICU, PICU, or neonatal ICU who were prescribed enoxaparin between January 2014 and March 2016 were studied. Interventions: One hundred ten patients were identified who had received IV or subcutaneous enoxaparin and had at least one postadministration peak antifactor Xa level documented. Measurements and Main Results: Of the 139 courses of enoxaparin administered, 96 were therapeutic dose courses (40 IV and 56 subcutaneous) and 43 were prophylactic dose courses (20 IV and 23 subcutaneous). Dosing, anticoagulation quality measurements, safety, and clinical efficacy were not significantly different between the two groups. Conclusions: Our study suggests that anticoagulation with IV enoxaparin infused over 30 minutes is a safe and an equally effective alternative to subcutaneous enoxaparin in critically ill infants and children.

Acquired von Willebrand Syndrome: An Under-Recognized Cause of Major Bleeding in the Cardiac Intensive Care Unit.

Background: Acquired von Willebrand syndrome (AvWS) in the setting of congenital heart disease is an under-recognized cause of bleeding in the pediatric cardiac critical care unit. Methods: Fourteen patients diagnosed with AvWS admitted to the cardiac intensive care unit at the Children’s National Health System between December 2009 and September 2015 were identified with subsequent chart review and case analysis. Results: Of the 14 patients included in this study, 4 patients were on ventricular-assist devices, 6 patients were on extracorporeal membrane oxygenation, and 4 were patients with congenital heart disease not receiving any mechanical circulatory support. All patients identified manifested persistent severe bleeding, despite appropriate management of anticoagulation and blood product administration based on the established protocols. Detailed hemostatic testing including quantitative von Willebrand factor (vWF) multimer analysis revealed decreased high-molecular-weight multimers (HMWMs) and absent ultra-HMWM, consistent with AvWS in all patients. Eight patients received treatment with vWF concentrate, one patient with desmopressin, and five recovered without specific treatment. Bleeding ceased in all but one patient. Conclusions: Acquired von Willebrand syndrome is an uncommon but important cause of bleeding in pediatric patients with cardiac disease. A high index of clinical suspicion with knowledge of the characteristic clinical scenario in addition to low levels of vWF multimers is required to manage and diagnose AvWS. Although the optimal management of AvWS in this patient population is unclear, vWF concentrates are available and appear to be efficacious for controlling life-threatening bleeding.

Reoperation rates after open and endovascular abdominal aortic aneurysm repairs

Objective: This study compared reoperation rates associated with open abdominal aortic aneurysm (AAA) repair (OR) outcomes vs endovascular AAA repair (EVAR). Methods: A retrospective review of the Veterans Affairs Surgical Quality Improvement Project data was performed with inclusion criteria defined as all patients who underwent AAA repair from October 1, 2007, to October 1, 2013. The primary outcome was the incidence of reoperations. Reoperations included subsequent OR or EVAR procedures performed on the abdominal aorta or iliac arteries, surgical treatment of temporally related bowel obstruction, as well as treatment of abdominal or groin wound complications ≤6 months and treatment of bowel or lower limb ischemia ≤10 days. Results: Of 6677 patients who underwent AAA repair, 476 (7.1%) required reoperations. OR was associated with a higher rate of reoperations overall (10.0% vs 6.3%; P < .01), with most being intra‐abdominal and wound complications. OR also had higher rates of bowel ischemia requiring operation (0.7% vs 0.3%; P = .01) and lower extremity ischemia (0.5% and 0.06%; P < .01). Significantly more endovascular stents were placed during EVAR (2.8% vs 0.5%; P < .01). Logistic regression showed EVAR is a negative predictor for reoperation after controlling for comorbidities (P < .001). Conclusions: The long‐term burden of reoperations after OR may actually be more significant than current understanding when including all possible abdominal complications in an extended analysis. Future prospective trials should include all potential reoperations extended >30 days with associated cost analysis. As surgical innovation in EVAR technology advances, complication comparisons with OR should undergo frequent re‐evaluation given that endovascular indications and outcomes continue to expand and improve.

Functional status as a predictor of outcomes in open and endovascular abdominal aortic aneurysm repair

Background: Functional status is a simple and rapidly assessable metric that may be used as a predictor for surgical outcomes. This study examined the association of functional status with short‐term mortality after abdominal aortic aneurysm (AAA) repair in octogenarians to characterize the utility of functional status as a means of preoperative risk assessment. Methods: All patients who underwent endovascular and open AAA repair from 2002 to 2010 within the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database were identified. Functional status, defined as an ordinal scale from 1 to 3 (1, independent; 2, partially dependent; 3, totally dependent), was examined using multivariate regression models with 30‐day mortality as the primary outcome. For the purpose of analysis, this 3‐point scale was converted into a binomial scale of function, with “normal” including 1 (completely independent) and “abnormal” including 2 or 3 (partially to totally dependent). Results: We identified 9030 patients who underwent AAA repair (46.6% open and 53.4% endovascular). Mortality at 30 days was 2.8% for the entire cohort (4.2% open, 1.7% endovascular; P < .001). There were 1340 patients aged ≥80 years, of which 67.3% underwent endovascular AAA repair. Among all age groups, functional status was a significant predictor of 30‐day mortality (<80 years, P < .001; ≥80 years, P < .001). The ≥80 cohort with abnormal function status also demonstrated increased operative mortality (P = .002), length of stay (P = .001), and incidence of pulmonary complications (P = .025) compared with the cohort with normal functional status. Multivariate logistic regression demonstrated that within the ≥80‐year‐old cohort, only functional status remained a significant predictor of mortality (P < .001). In addition, the strength of the association between functional status and mortality was greater in the older cohort than in the younger one (Cox regression hazard ratio: 3.13 vs 2.18). Conclusions: Functional status is a simple and rapidly applicable predictor of mortality within AAA patients and may be a useful tool to help preoperatively risk‐stratify elderly patients presenting with AAA in need of repair. Further studies are needed to understand how best to apply these data to the clinical setting to guide preoperative decision making.

Perceptions of Bedside Cardiac Critical Care Registered Nurses on 24 Hour Attending Intensivist Coverage

OBJECTIVE To elicit the perceptions of bedside critical care nurses toward continual in-house attending coverage and its effect on patient safety, communication, and nursing education. DESIGN A 5-point Likert-type questionnaire was designed to evaluate the perception of bedside nurses in the pediatric cardiac intensive care unit (PCICU) toward the presence of a 24 hour in-house attending physician. SETTING Single tertiary referral PCICU in Washington, DC SUBJECTS: The 46 PCICU nurses who participated in the study were separated into two groups based on exposure to the recent implementation of continual in-house attending coverage at our institution. Group one consisted of 14 nurses with only exposure to the new 24/7 in-house coverage while group two encompassed 32 nurses who had experienced both the new and old system (off-site on-demand attending physician). MEASUREMENTS AND MAIN RESULTS Surveys demonstrated that both groups found that the new system has a positive impact on nursing education (median score of 5) as well as a positive impact on the communication between multidisciplinary teams and between care team and families (median score of 5). Nurses who experienced only the new system scored one point lower (median score of 4) regarding the effect of this staffing model on patient outcomes than nurses who had experienced both systems (median score of 5, P = .016). Between 83% and 98% of all 46 nurses who participated indicated they agree or strongly agree with each of the questions regarding the benefit of 24 hour in-house attending coverage. CONCLUSION Our study suggests that regardless of differences in experience, pediatric cardiac nurses believe the presence of an on-site intensivist to be beneficial to both nursing and patients.

Risk of tumor transmission after thoracic allograft transplantation from adult donors with central nervous system neoplasm‐a UNOS database study

We analyzed the UNOS database to better define the risk of transmission of central nervous system (CNS) tumors from donors to adult recipients of thoracic organs.

Outcomes of Beating Heart on Pump Utilizing a Miniature Bypass Circuit Versus off Pump Cardiac Bypass at a Veterans Affairs Medical Center.

BACKGROUND Off-pump coronary artery bypass grafting (OPCAB) helps reduce systemic inflammatory changes by maintaining native pulsatile flow. This analysis evaluates the outcomes of OPCAB at a Veterans Affairs Medical Center (VAMC) and evaluates the use of beating heart on-pump (BHOP) bypass grafting as an empiric therapy for high-risk patients. METHODS We performed a retrospective analysis of 756 patients who underwent coronary bypass grafting between 2004-2015 at a single VAMC. This group was subdivided into BHOP (N.=60) versus OPCAB (N.=696). Analysis was performed using multivariate regression modeling with P=0.05 holding statistical significance. RESULTS Both cohorts were predominantly male with an average age of 65 years and average Body Mass Index of 30 kg/m2. Individuals in the BHOP group were more likely to have COPD and resting ST depressions preoperatively. Operative time was longer and average number of conduits was higher for BHOP cases compared to OPCAB cases respectively. After controlling for differences between cohorts, multivariate regression analysis showed a protective effect of both BHOP (OR 0.325, P=0.035; OR 0.323, P=0.031) and two (OR 0.385, P<0.001; OR 0.539, P=0.018) and three (OR 0.154, P<0.001; OR 0.315, P<0.001) vessel revascularization on three and six-year mortality following revascularization. CONCLUSIONS Postoperative survival following BHOP is superior to OPCAB when BHOP is used empirically with no difference in short-term mortality. Empiric use of BHOP should be considered for high risk coronary revascularization.

Rapid Response Extracorporeal Membrane Oxygenation Deployment—Surgical Technique:

The availability of extracorporeal membrane oxygenation (ECMO) is the standard of care at most high-acuity congenital heart surgery programs. Extracorporeal membrane oxygenation is also an integral part of managing children with in-hospital cardiac arrest refractory to conventional cardiopulmonary resuscitation (extracorporeal cardiopulmonary resuscitation). In this article, we aim to provide a practical guide to initiate rapid ECMO in a nonoperating room setting.

Intracardiac tumor causing left-ventricular outflow-tract obstruction in a newborn

The following report describes the case of newborn girl with an asymptomatic systolic murmur, which on imaging revealed a nearly obstructive mass in the left-ventricular outflow tract. The mass was resected and found to be consistent with a rhabdomyoma. Here, we describe the pathologic and clinical characteristics of this tumor.

Role and Rationale for Hybrid Coronary Artery Revascularization

The optimal revascularization strategy for patients with multi-vessel coronary artery disease remains controversial. The advent of percutaneous coronary intervention (PCI) has challenged the superiority of coronary artery bypass graft (CABG) surgery for multi-vessel disease. In the late 1990s, an integrated approach, now referred to as “hybrid coronary revascularization” (HCR), was pioneered combining CABG and PCI to offer appropriate patients a less invasive option for revascularization while still capitalizing on the superior patency rates of the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery bypass . The operative techniques continue to evolve as well as the timing strategies for intervention and use of antiplatelet therapy. While more research is needed, current data supports hybrid coronary revascularization as a promising technique to optimize outcomes in patients with multi-vessel coronary artery disease.