Nikhil K. Chanani

Collaborative quality improvement in the cardiac intensive care unit: development of the Paediatric Cardiac Critical Care Consortium (PC4)

Despite many advances in recent years for patients with critical paediatric and congenital cardiac disease, significant variation in outcomes remains across hospitals. Collaborative quality improvement has enhanced the quality and value of health care across specialties, partly by determining the reasons for variation and targeting strategies to reduce it. Developing an infrastructure for collaborative quality improvement in paediatric cardiac critical care holds promise for developing benchmarks of quality, to reduce preventable mortality and morbidity, optimise the long-term health of patients with critical congenital cardiovascular disease, and reduce unnecessary resource utilisation in the cardiac intensive care unit environment. The Pediatric Cardiac Critical Care Consortium (PC4) has been modelled after successful collaborative quality improvement initiatives, and is positioned to provide the data platform necessary to realise these objectives. We describe the development of PC4 including the philosophical, organisational, and infrastructural components that will facilitate collaborative quality improvement in paediatric cardiac critical care.

Heterotaxy Syndrome Proceedings From the 10th International PCICS Meeting

A session dedicated to heterotaxy syndrome was included in the program of the Tenth International Conference of the Pediatric Cardiac Intensive Care Society in Miami, Florida in December 2014. An invited panel of experts reviewed the anatomic considerations, surgical considerations, noncardiac issues, and long-term outcomes in this challenging group of patients. The presentations, summarized in this article, reflect the current approach to this complex multiorgan syndrome and highlight future areas of clinical interest and research.

Perioperative feeding management of neonates with CHD: Analysis of the Pediatric Cardiac Critical Care Consortium (PC4) registry

UNLABELLED Introduction The optimal perioperative feeding strategies for neonates with CHD are unknown. In the present study, we describe the current feeding practices across a multi-institutional cohort. METHODS Inclusion criteria for this study were as follows: all neonates undergoing cardiac surgery admitted to the cardiac ICU for ⩾24 hours preoperatively between October, 2013 and July, 2014 in the Pediatric Cardiac Critical Care Consortium registry. RESULTS The cohort included 251 patients from eight centres. The most common diagnoses included the following: hypoplastic left heart syndrome (17%), coarctation/aortic arch hypoplasia (18%), and transposition of the great arteries (22%); 14% of the patients were <37weeks of gestational age. The median total hospital length of stay was 21 days (interquartile range (IQR) 14-35) and overall mortality was 8%. Preoperative feeding occurred in 133 (53%) patients. The overall preoperative feeding rates across centres ranged from 29 to 79%. Postoperative feeds started on median day 2 (IQR 1-4); for patients with hypoplastic left heart syndrome postoperative feeds started on median day 4. Postoperative feeds were initiated in 89 (35%) patients before extubation (range across centres: 21-61%). The median cardiac ICU discharge feeding volume was 108 cc/kg/day, varying across centres. The mean discharge weight was 280 g above birth weight, ranging from +100 to 430 g across centres. A total of 110 (44%) patients had discharge feeding tubes, ranging from 6 to 80% across centres, and 40/110 patients had gastrostomy/enterostomy tubes placed. In addition, eight (3.2%) patients developed necrotising enterocolitis - three preoperatively and five postoperatively. CONCLUSION In this cohort, neonatal feeding practices and outcomes appear to vary across diagnostic groups and institutions. Only half of the patients received preoperative enteral nutrition; almost half had discharge feeding tubes. Multi-institutional collaboration is necessary to determine feeding strategies associated with best clinical outcomes.

B-type natriuretic peptide in the recognition of critical congenital heart disease in the newborn infant.

Objective Infants with congenital heart disease having obstruction to the left ventricular outflow and ductal-dependent systemic circulation can present critically ill with shock. Prompt disease recognition and initiation of prostaglandins are necessary to prevent excess morbidity and mortality. We assessed a large cohort of newborn infants with ductal-dependent systemic circulation to determine if B-type natriuretic peptide (BNP) is consistently elevated at presentation, potentially aiding in diagnosis and treatment. Methods The clinical records of infants with left-sided obstructive lesions admitted from January 2005 to June 2009 were reviewed. Infants were divided into 2 groups: group 1 was diagnosed with cardiogenic/circulatory shock at presentation, and group 2 consisted of infants with ductal-dependent systemic circulation without evidence of shock. B-type natriuretic peptide levels and other variables between the groups were compared. Results All patients with critical congenital heart disease presenting with shock had elevated BNP levels, ranging from 553 to greater than 5000 pg/mL. Infants in group 1 (shock, n = 36) had significantly higher median BNP levels of 4100 pg/mL at presentation compared with group 2 patients (no shock, n = 86), who had a median BNP of 656 pg/mL (range, 30–3930 pg/mL; P < 0.001). Every 100 U of increase in BNP at presentation increased the likelihood of shock (odds ratio, 100; P < 0.001). Conclusions B-type natriuretic peptide is markedly elevated in neonates presenting in shock secondary to left-sided obstructive heart disease and is an important diagnostic tool to aid in the rapid identification and treatment of these patients.

icuARM-II: improving the reliability of personalized risk prediction in pediatric intensive care units

Clinicians in intensive care units (ICUs) rely on standardized scores as risk prediction models to predict a patients vulnerability to life-threatening events. Current scales calculate scores from a fixed set of conditions collected within a specific time window. However, modern monitoring technologies generate complex, temporal, and multimodal patient data that conventional prediction scales cannot fully utilize. Thus, a more sophisticated model is needed to tailor individual characteristics and incorporate multiple temporal modalities for a personalized risk prediction. Furthermore, most scales focus on adult patients. To address this need, we propose a new ICU risk prediction system, called icuARM-II, using a large-scaled pediatric ICU database from Childrens Healthcare of Atlanta. This novel database contains clinical data collected in 5,739 ICU visits from 4,975 patients. We propose a temporal association rule mining framework giving a potential to predict risks based on all available conditions without being restricted by a fixed observation window. We also develop a new metric that rigidly assesses the reliability of all generated association rules. In addition, icuARM-II features an interactive user interface. Using icuARM-II, our results showed a use case of short-term mortality prediction using lab testing results, which demonstrated a potential for reliable ICU risk prediction using personalized clinical data in a previously neglected population.

Epidemiology of noninvasive ventilation in pediatric cardiac ICUs

Objective: To describe the epidemiology of noninvasive ventilation therapy for patients admitted to pediatric cardiac ICUs and to assess practice variation across hospitals. Design: Retrospective cohort study using prospectively collected clinical registry data. Setting: Pediatric Cardiac Critical Care Consortium clinical registry. Patients: Patients admitted to cardiac ICUs at PC4 hospitals. Interventions: None. Measurements and Main Results: We analyzed all cardiac ICU encounters that included any respiratory support from October 2013 to December 2015. Noninvasive ventilation therapy included high flow nasal cannula and positive airway pressure support. We compared patient and, when relevant, perioperative characteristics of those receiving noninvasive ventilation to all others. Subgroup analysis was performed on neonates and infants undergoing major cardiovascular surgery. To examine duration of respiratory support, we created a casemix-adjustment model and calculated adjusted mean durations of total respiratory support (mechanical ventilation + noninvasive ventilation), mechanical ventilation, and noninvasive ventilation. We compared adjusted duration of support across hospitals. The cohort included 8,940 encounters from 15 hospitals: 3,950 (44%) received noninvasive ventilation and 72% were neonates and infants. Medical encounters were more likely to include noninvasive ventilation than surgical. In surgical neonates and infants, 2,032 (55%) received postoperative noninvasive ventilation. Neonates, extracardiac anomalies, single ventricle, procedure complexity, preoperative respiratory support, mechanical ventilation duration, and postoperative disease severity were associated with noninvasive ventilation therapy (p < 0.001 for all). Across hospitals, noninvasive ventilation use ranged from 32% to 65%, and adjusted mean noninvasive ventilation duration ranged from 1 to 4 days (3-d observed mean). Duration of total adjusted respiratory support was more strongly correlated with duration of mechanical ventilation compared with noninvasive ventilation (Pearson r = 0.93 vs 0.71, respectively). Conclusions: Noninvasive ventilation use is common in cardiac ICUs, especially in patients admitted for medical conditions, infants, and those undergoing high complexity surgery. We observed wide variation in noninvasive ventilation use across hospitals, though the primary driver of total respiratory support time seems to be duration of mechanical ventilation.

Portable CT Pulmonary Angiogram in an Infant on Veno-Arterial Extracorporeal Membrane Oxygenation in the Pediatric Intensive Care Unit

PURPOSE Computed tomography (CT) has been shown to change management in children on extracorporeal membrane oxygenation (ECMO). Although techniques have been described to transport these critically ill patients to the CT suite in the radiology department, transport out of the intensive care setting is not without risk, and using portable CT is a practical alternative. However, obtaining a CT pulmonary angiogram (CTPA) in a patient on veno-arterial (VA) ECMO presents unique challenges due to bypass of the cardiopulmonary system, which may lead to suboptimal opacification of the pulmonary arteries. METHODS We describe a method to obtain a diagnostic CTPA study in an infant on VA ECMO in the intensive care unit using portable CT. Our solution involved temporary withholding ECMO and using the venous cannula to deliver a compact contrast bolus to the right atrium to adequately opacify the pulmonary arteries. Special attention was given to the delivery of the contrast bolus, which was given by hand injection, to ensure it coincided with image acquisition and minimized the time ECMO was withheld. RESULTS We were able to successfully obtain a diagnostic CTPA study in an infant on VA ECMO in the intensive care unit using portable CT. CONCLUSION This case demonstrates that in select instances CTPA in infants on VA ECMO can be achieved using a portable CT system.

PEPCOR — A risk prediction model for pediatric intensive care units utilizing ventilator days and length of stay

Great sources of concern for pediatric and neonatal intensive care units are the total resource utilization and cost of caring for very sick children. This paper attempts to create a usable clinical decision support system (PEPCOR) that would help improve personalized health care and avoid unnecessary secondary, and costly, procedures that do not improve the care of a critically ill patient. The system uses the Childrens Healthcare of Atlanta ICU database to analyze the effects on the risk, (quantified as the risk of invasive ventilation and associated complications) when combining two procedures versus administering one procedure without the other. The risk is calculated by computing the ratio of ventilator days to the length of stay, with a higher risk score indicating the second procedure did not improve the overall health of the patient. 82/90 of the procedure combinations showed a statistically significant difference with a p-value <; 0.05 when the stand-alone procedure was compared to the combination of two procedures.