María Althabe

Dying in the intensive care unit: collaborative multicenter study about forgoing life-sustaining treatment in Argentine pediatric intensive care units.

Objective Describe modes of death and factors involved in decision-making together with life support limitation (LSL) procedures. Design Prospective, descriptive, longitudinal, and noninterventional study. Setting Sixteen pediatric intensive care units in Argentina. Patients Every patient who died during a 1-yr period was included. Measurements and Main Results Age, sex, length of stay (LOS), primary and admission diagnosis, underlying chronic disease (CD), postoperative condition (PO). Deaths were classified in four groups: a) failed cardiopulmonary resuscitation (CPR); b) do-not-resuscitate (DNR) status; c) withholding or withdrawing life-sustaining treatment (WH/WD); and d) brain death (BD). Justifications were classified as a) imminent death; b) poor long-term prognosis; c) poor quality of life; and d) family request. Data were collected from medical records and interviews with the attending physicians. Descriptive statistics were performed. Differences among groups were analyzed through contingency tables and analysis of variance when required. Relative risks and confidence intervals of variables potentially related to LSL were analyzed, and logistic regression was performed. There were 6358 admissions and 457 deaths. CPR was performed in 52%, DNR in 16%, WH/WD in 20%, and BD in 11% of dead patients. BD patients were older, LOS and CD prevalence were higher in the WH/WD group. Inotropic drugs were the most frequently limited treatment in 110 patients (55%), CPR in 72 (35.6%), and mechanical ventilation in 63 (31%). Imminent death was the most frequently reported justification for LSL. CD and more staff were associated with a higher probability of LSL. Conclusions Most of the patients in Argentina underwent CPR before their death. We have a high proportion of patients with CD (65%) and low BD diagnosis. PO condition decreased LSL probability in chronically ill patients. Do-not-resuscitate orders and withholding new treatments were the most common LSL. Active withdrawal was exceptional. The Ethics Committee was consulted in 5% of the LSL population.

Levosimendán, un nuevo agente inotrópico: experiencia en niños con fallo cardíaco agudo

INTRODUCTION Low cardiac output syndrome occurs frequently in pediatric patients after cardiac surgery. Catecholamines are used as inotropic drugs to treat this threatening condition, but may cause undesirable and potentially harmful side effects. This study was performed to evaluate the efficacy and safety of levosimendan (LEVO) in pediatric patients with low cardiac output syndrome. PATIENTS AND METHODS Open prospective, quasi-experimental cohort. LEVO was given as compassionate treatment in patients with refractory post-surgical low cardiac output syndrome. Every patient received an IV infusion of LEVO at 6 microg/kg during a fifteen minutes period, followed by a 24 h IV infusion at 0.1 microg/kg/min. Clinical improvement of cardiac output was the primary end point of the study. Two independent observers performed clinical evaluation, bidimensional echocardiogram, hemodynamic and laboratory tests were performed pre and after LEVO infusion. RESULTS LEVO was infused in 18 opportunities (fourteen children). The response was considered successful in 9/18 interventions (50%; p= 0.004). Both inotropic score (12.1 vs. 6,1, p= 0.01) and A-VDO(2)2 (26.78 +/- 11.5% vs. 20.81 +/- 7.72%, p= 0.029) showed reduction, while SvO2 improved (69.5 +/- 11.4% vs. 76 +/- 9.29%, p= 0.03). No adverse effects were noticed. Four patients died, none of them related to LEVO administration. CONCLUSIONS LEVO improved cardiac output in 50% of the interventions with post-surgical LCOS and no adverse effect was observed.

Cirugía cardíaca reparadora en recién nacidos: Experiencia de 5 años en cirugía neonatal con circulación extracorpórea

INTRODUCTION Four hundred newborns die every year in our country suffering from congenital heart disease. Definitive surgical repair, whenever possible, is nowadays the optimal therapeutic strategy. Our goal is to describe mortality and morbidity in neonatal surgery with cardiopulmonary bypass in a tertiary public hospital in Argentina. PATIENTS AND METHODS Descriptive, retrospective study. Every patient, younger than 45 days, with cardiac surgery requiring cardiopulmonary bypass, at the Garrahan Hospital between 2004 and 2008 was included. Demographic, surgical and postoperative data were collected. Adjusted mortality risk analysis, and descriptive statistics from the most frequent diagnosis were performed. Results are expressed as median and rank or percentage. RESULTS 200 newborns were operated, 62% males. Median age was 21 days (r 1- 45) and median weight 3.1 kg (r 1.6-6.2). Total anomalous pulmonary venous return, transposition of great arteries an hypoplastic left heart syndrome diagnoses accounted for 75% of the procedures. Median length of stay was 12 days (r 0-191), and 6 days of mechanical ventilation (r 0-180). Eighteen percent of the patients required peritoneal dialysis. Whole series mortality was 19% and fell to 14% in 2008. Unstable preoperative condition and postoperative complications increased mortality, OR= 2.23 (1.02-4.89) and OR= 10 (3.6-33.4), respectively. CONCLUSIONS Our postoperative mortality is similar to those reported in foreign countries databases. Patients with unstable preoperative condition and post-operative complications had higher mortality.

Impact of the time of diagnosis on the postoperative outcome of newborn infants with congenital heart disease in a public hospital in Argentina

Congenital heart diseases account for 13% of child mortality, and late diagnosis increases morbidity and mortality. The objective of this study was to assess the impact of the time of diagnosis in newborn infants on the postoperative course. The time of diagnosis was classified into prenatal, before or after discharge from the maternity center. Two hundred ninety-nine patients were included; their gestational age was 38 ± 2.6 weeks and their birth weight was 3.22 ± 0.6 kg. Two hundred sixty-six patients underwent surgery, 13 were excluded due to the characteristics of the lesion, and 10 because of hemodynamic collapse, while 10 were treated at the Cath Lab or were operated beyond the neonatal period. Only 19 patients (7%) were diagnosed before birth; most were patients who had health insurance, lived in the City of Buenos Aires or in capital cities of other provinces. The time of diagnosis was not associated with differences in mortality; however, an association was observed with a poor preoperative clinical status, with 3.6% of patients who died before surgery. Postoperative survival was 89.5%; overall survival was 83%.

Mechanical circulatory support in pediatrics: Experience at the Hospital de Pediatría Dr. Juan P. Garrahan. Argentina

INTRODUCTION Mechanical circulatory support provides oxygen to the tissues in patients with cardiac and/or respiratory reversible disease refractory to conventional treatments. OBJECTIVE The aim of this study is to show our initial results of mechanical circulatory support in children with heart disease. METHOD Retrospective cohort between March 2006 and March 2012. Demographic data (age, sex, weight, cardiac diagnosis), surgery (technique, pump, aortic cross clamping time) and mechanical circulatory support (type of assistance, indication, duration, complications and outcome) were collected. RESULTS Thirty-three patients were supported (1.3% of all surgeries), extracorporeal membrane oxygenation 32 cases and one ventricular assist device. The median age 7.4 months (one day-18 years) and weight 6kg (2.3-75). The most frequent cardiac malformations supported were the transpositions of the great arteries associated with other anomalies and the corrected transpositions (ventricular inversion or double discordance). The most common reason for admission was post-cardiotomy biventricular dysfunction. Twenty-eight patients were supported in the postoperative period, 4 in the preoperative period and in one with myocarditis. Median days of support were 3 days (1-10). The most common complications were infection (21%), bleeding (21%). Elective decannulation was achieved in 94% of cases. Hospital discharge survival: 52%. CONCLUSIONS The mechanical circulatory support in our institution is a safe and standard procedure. We have been using it in a small number of cases with a similar survival to that reported internationally. This complex procedure is widely justified because it allows for the recovery of more than half of the patients who otherwise would have died.

Asistencia circulatoria mecánica en pediatría. Experiencia en el Hospital de Pediatría Dr. Juan P. Garrahan. Argentina

INTRODUCTION Mechanical circulatory support provides oxygen to the tissues in patients with cardiac and/or respiratory reversible disease refractory to conventional treatments. OBJECTIVE The aim of this study is to show our initial results of mechanical circulatory support in children with heart disease. METHOD Retrospective cohort between March 2006 and March 2012. Demographic data (age, sex, weight, cardiac diagnosis), surgery (technique, pump, aortic cross clamping time) and mechanical circulatory support (type of assistance, indication, duration, complications and outcome) were collected. RESULTS Thirty-three patients were supported (1.3% of all surgeries), extracorporeal membrane oxygenation 32 cases and one ventricular assist device. The median age 7.4 months (one day-18 years) and weight 6kg (2.3-75). The most frequent cardiac malformations supported were the transpositions of the great arteries associated with other anomalies and the corrected transpositions (ventricular inversion or double discordance). The most common reason for admission was post-cardiotomy biventricular dysfunction. Twenty-eight patients were supported in the postoperative period, 4 in the preoperative period and in one with myocarditis. Median days of support were 3 days (1-10). The most common complications were infection (21%), bleeding (21%). Elective decannulation was achieved in 94% of cases. Hospital discharge survival: 52%. CONCLUSIONS The mechanical circulatory support in our institution is a safe and standard procedure. We have been using it in a small number of cases with a similar survival to that reported internationally. This complex procedure is widely justified because it allows for the recovery of more than half of the patients who otherwise would have died.