Sarah LeRoy

An introduction to critical paths.

A critical path defines the optimal sequencing and timing of interventions by physicians, nurses, and other staff for a particular diagnosis or procedure. Critical paths are developed through collaborative efforts of physicians, nurses, pharmacists, and others to improve the quality and value of patient care. They are designed to minimize delays and resource utilization and to maximize quality of care. Critical paths have been shown to reduce variation in the care provided, facilitate expected outcomes, reduce delays, reduce length of stay, and improve cost-effectiveness. The approach and goals of critical paths are consistent with those of total quality management (TQM) and can be an important part of an organizations TQM process.

Use of radiofrequency current to ablate accessory connections in children.

BackgroundSeveral investigators have recently ablated electrophysiologically mapped accessory connections in the adult human myocardium by using radiofrequency current. To examine the effectiveness and safety of radiofrequency current for ablation of accessory connections in children, 20 consecutive patients (age, 3–18 years) with preexcitation and/or supraventricular tachycardia were evaluated by electrophysiological study. Methods and ResultsNineteen of the 20 patients were completely studied and demonstrated accessory connections. After identification of the earliest retrograde atrial activation site, a steerable 7F catheter (with a 4-mm-long electrode at the distal tip) was placed within the ventricular cavity ipsilateral to the accessory connection and positioned at the atrioventricular valve annulus directly opposite the earliest point of retrograde atrial activation. Radiofrequency current was delivered at 50–65 volts for 10–60 seconds at a frequency of 500 kHz. Radiofrequency pulses were delivered for two to 26 trials. Upon completion of radiofrequency trials, repeat electrophysiological testing was performed. Thirteen of 19 subjects (68%) experienced definite successful ablation of their accessory pathway; an additional patient had probable successful ablation, yielding an overall success rate of 74%. Eighty-seven percent of individuals with a left-sided pathway had permanent ablation and 100% with a manifest left-sided pathway experienced successful ablation. Only 29% of the first seven patients had a successful result; in contrast, 92% of the next 12 patients had successful interruption of their accessory pathways. After ablation, 4-day continuous electrocardiographic telemetry disclosed no significant arrhythmias. CPK enzyme rises peaked at 12–24 hours. The rise was excessive and associated with general anesthesia in five patients. The isoenzyme MB fraction rose mildly in five other patients and returned to normal within 72 hours. No clinical or electrocardiographic evidence of myocardial ischemia was detected. Follow-up for 4–12 months indicates no return of preexcitation or tachycardia in any patient whose accessory connection was successfully ablated. ConclusionsThis experience indicates that radiofrequency current is an effective and safe technique for ablation of accessory connectionsin children.

Implantable Cardioverter Defibrillator Therapy for Life-Threatening Arrhythmias in Young Patients

AbstractObjectives: This study examined the indications, efficacy and outcomes of implantable cardioverter defibrillator (ICD) use in the pediatric population. Background: ICDs are first-line therapy for adults resuscitated from sudden cardiac death (SCD) or at high risk for life-threatening ventricular arrhythmias. Use of ICDs in children and young adults is infrequent and there are few data regarding this group. Methods: We abstracted and analyzed data for all patients in whom ICDs were implanted. Results: A total of 38 devices were implanted in 27 patients. Age ranged from 6 to 26 years (mean, 14) and weight ranged from 16 to 124 kg (mean, 47). Diagnoses included long QT syndrome (9), hypertrophic cardiomyopathy [6], repaired congenital heart disease [5];, and idiopathic ventricular tachycardia/fibrillation [4]. Indications comprised resuscitated SCD [15], syncope [9], and life-threatening ventricular arrhythmia [3]. Initial device placement was infraclavicular in 13, abdominal in 13 and intrathoracic in 1. Epicardial leads were used with 5 systems. A single coil lead was used in 17. Seven patients, all previously resuscitated from SCD, experienced 88 appropriate successful discharges. There were 6 inappropriate discharges in 3 patients. Mean time to device replacement was 3.1 years (n = 11). Complications included 2 infected systems, 2 lead dislodgments, 2 lead fractures, 1 post-pericardiotomy syndrome, 1 adverse event with defibrillation threshold (DFT); testing, and 1 patient with psychiatric sequelae. No deaths occurred with implanted ICDs. Conclusions: These data demonstrate that ICDs provide safe and effective therapy in young patients. The indications for ICDs as primary preventive therapy remain uncertain.

Recommendations for Preparing Children and Adolescents for Invasive Cardiac Procedures A Statement From the American Heart Association Pediatric Nursing Subcommittee of the Council on Cardiovascular Nursing in Collaboration With the Council on Cardiovascular Diseases of the Young

Staged surgical repair and interventional cardiac catheterization have contributed to improved outcomes for children with congenital heart disease. As a result, there are increasing numbers of children and adolescents who must undergo multiple invasive cardiac procedures at various developmental stages. During these procedures, management of pain and anxiety using nonpharmacological methods is especially important, given the limitation in the types of medications that can be used and the potential for side effects with larger dosages. In addition, children may be particularly vulnerable to the stress associated with invasive medical procedures; several studies document frequent and persistent severe distress reactions after aversive hospital experiences.1–6 Although numerous studies document the efficacy of psychological preprocedure preparation for children and adolescents,7–12 implementation of these interventions remains inconsistent.13 The following guidelines, based on review of the literature and expert consensus, were developed to facilitate systematic implementation of preprocedure preparation for pediatric patients undergoing invasive cardiac procedures. Congenital heart disease affects 8 per 1000 live births, and 2 or 3 of these infants are estimated to have critical disease requiring cardiac catheterization or cardiac surgery.14 Over the past 2 decades, there have been remarkable improvements in medical and surgical treatment, including successful performance of complete repair during early infancy and staged repair for complex single-ventricle defects. Although newer treatments have resulted in significant improvements in survival, disease-related morbidity, including psychosocial adjustment problems, remains a significant source of concern.15–17 Child adjustment problems have been linked with stressful hospital experiences since the early 1950s, with published reports of anger, aggression, panic, apathy, anxiety, sleep disturbances, and separation anxiety during hospitalization that persist after hospital discharge.1,3,18–20 Stressors for children undergoing hospitalization and/or invasive medical procedures include (1) physical harm or bodily injury resulting in discomfort, pain, mutilation, or death; (2) separation from parents …

Access to the Left Atrium for Delivery of Radiofrequency Ablation in Young Patients: Retrograde Aortic vs Transseptal Approach

Abstract. Reported experience with the transseptal approach to the left atrium for delivery of radiofrequency energy in the young patient is limited. To compare two approaches for radiofrequency ablation (RFA) in the left atrium we reviewed our experience from January 1, 1991, through February 1, 1999, in 154 procedures performed on 136 patients (mean age 12.2 years). The patients were grouped by either the retrograde aortic route (R, n= 30) or the transseptal atrial route (T, n= 106). No significant differences were found in age, weight, height, supraventricular tachycardia cycle length, or electrocardiograph characteristics (manifest vs concealed accessory pathway) between the two approaches. Comparison of the transseptal group to the retrograde aortic group revealed a significant difference in the number of catheters (mean = 4 R vs 3 T, p < 0.0001), total fluoroscopic time (71.3 min R vs 43.0 min T, p= 0.0007), diagnostic fluoroscopic time (40.2 min R vs 16.6 min T, p < 0.0001), ablation fluoroscopic time (44.7 min R vs 25.3 min T, p= 0.019), and procedure time (5.0 hours R vs 4.1 hours T, p < 0.0001). No significant difference was found in success rate, number of radiofrequency applications, or major complication rate. These data suggest that although outcomes and major complication rates are similar for the two groups, the use of fewer catheters and shorter fluoroscopic times warrant consideration of the transseptal atrial approach in young patients.

Use of a single coil transvenous electrode with an abdominally placed implantable cardioverter defibrillator in children.

While transvenous defibrillator electrode placement avoiding a thoracotomy is preferable, electrode size, a large intercoil spacing, and the need for subclavicular device placement preclude this approach in most children. We investigated a single RV coil to an abdominally placed active can ICD device. Five children ages 8–16 years (weight 21–50 kg, mean 35 kg) underwent ICD placement. Placement of a single coil Medtronic model 6932 or 6943 electrode was performed via the left subclavian vein approach and the electrode positioned in the RV apex with the coil lying along the RV diaphragmatic surface. The ICD (Medtronic Micro Jewel II model 7223Cx) was implanted in a left abdominal pocket with the lead tunneled from the infraclavicular region to the pocket. Implant DFTs were ± 15 J using a biphasic waveform. DFTs rechecked within 3‐month postimplant were unchanged. Lead impedance at implant ranged from 38 to 56 Ω, mean 51 Ω. Follow‐up was 3–21 months (total 82 months) with no electrode dislodgment. lead fractures, or inappropriate discharges. Two of the five patients have had successful appropriate ICD discharges. Transvenous ICD electrode placement can be performed in children as small as 20 kg with the device implanted in a cosmetically acceptable abdominal pocket that is well tolerated. Excellent DFTs can be achieved. This approach avoids a thoracotomy in all but the smallest child, does not require subclavicular placement of the device, and avoids use of a second intravascular coil.

The pediatric nurse practitioner as case manager in the delivery of services to Children with heart disease

Todays health care environment prompted implementation of a case management model by pediatric nurse practitioner clinical nurse specialists to promote the organization of resources for optimal care of children with heart disease. Evaluation of this pilot program suggests that achievement of expected outcomes within an appropriate length of stay was facilitated, that parents were ready for discharge, and that readmissions were infrequent. In addition, patient and system variances resulting in delay of discharge and discharge preparation needs were identified. The pediatric nurse practitioner as case manager may have a significant impact on the quality and cost of care for hospitalized children.

Clinical Dysrhythmias After Surgical Repair of Congenital Heart Disease

Innovations in surgical and medical treatment continue to improve the outlook for children with complex congenital heart disease. Although mortality continues to decrease, disease-related morbidity is increasing as a large cohort of these patients is reaching young adulthood, pursuing careers, marrying, and in many cases having children of their own. Chronic recurrent dysrhythmias are a frequent cause of long-term morbidity in this population and result in frequent, unanticipated emergency room visits and hospitalizations. Although not usually life threatening, they can pose considerable challenges to the patients and the providers who care for them. This article provides an overview of the most common dysrhythmias encountered in this population, dysrhythmia substrates, and therapeutic options.

Long QT Syndrome and Other Repolarization-related Dysrhythmias

Until recently, sudden cardiac death in a young person often remained an unexplained tragedy. However, in the last decade there have been dramatic advances in medical knowledge regarding inheritable dysrhythmias that increase the risk of SCD in otherwise healthy young individuals. The primary mechanism in this group of dysrhythmias appears to be an alteration of cardiac repolarization. In some diseases, the specific genes affected and even precise cellular mechanisms have been identified. The information about these diseases is often complex and rapidly evolving, challenging both healthcare providers and the families who must make important decisions based on emerging and incomplete information. The purpose of this article is to describe current understanding of the repolarization-related dysrhythmias and discuss the clinical implications for advanced practice nurses.

Electrogram Patterns Associated with Successful Radiofrequency Ablation of Accessory Pathways in Children

Electrograms observed prior to successful and unsuccessful ablation trials in 33 patients (362 attempts) with manifest pathways and 18 patients (194 attempts) with concealed pathways were compared to identify the electrogram patterns that are associated with successful radiofrequency ablation of accessory atrioventricular connections in young patients (mean age 12.7 years; range 4–22 years). Success, was defined as permanent or transient interruption of conduction in the accessory connection. Predictors of success in patients with manifest pathways were local ventricular preexcitation (p=0.0001), left-sidedness (43 or 174) of the accessory connection compared (p=0.04) to right-sidedness (27 of 172), a probable Kent bundle potential (29 of 84 versus 39 of 256;p=0.0001), and short antegrade atrioventricular conduction intervals (53.1±31.9 ms versus 64.6±32.0 ms;p=0.02). Predictors of success in patients with concealed pathways were short ventriculoatrial conduction times (103.3±35.8 ms versus 117.9±34.8 ms;p=0.01), and left-sided (42 of 125) pathways (p=0.03; versus right-sided, 11 of 60). The presence of a Kent bundle potential was not significant. We conclude that specific electrogram patterns can predict successful ablation of either manifest or concealed accessory pathways. Use of these criteria may reduce the delivery of unnecessary energy to young myocardium.