Pediatric Grand Rounds University TX Health 2/05/2016 ... · Science Center at San Antonio ... adverse outcomes in neonates with critical congenital heart disease, ... Pediatric Heart

Pediatric Grand Rounds ‐ University of TX Health Science Center at San Antonio

2/05/2016

1

Pediatric Cardiac Critical Care:Is it that complicated?

Objectives

At the end of this presentation the participant will be able to:

1. relate the complexity of decision making in and functioning of a pediatric cardiac unit

2. improve their understanding of concept of oxygen delivery in the context of a cardiac unit

3. help ease the presenter’s conscience so as to not be as guilt‐ridden when he sees Dr. Conrad or gets an email from him

Pediatric & Congenital Cardiac Unit

Complexity: Patient

• Diversity of anatomy even within an anomaly

• Dominant physiology

Example – “more desaturated”

Shunt: Right‐to‐Left

Obstructive

Myocardial performance

Other – non‐cardio‐pulmonary

Complexity: Patient

• Stage of development

Premature Neonate

Neonate

Child

Teen to Adult

Infant

Maturationvs.Weight?


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Low-weight infants are at increased mor tality r isk after palliativeor corrective cardiac surgery

Bahaaldin Alsoufi, MD,aCedric Manlhiot, BSc,b William T. Mahle, MD,c Brian Kogon, MD,a

William L. Border, MBChB, MPH,c Angel Cuadrado, MD,c Robert Vincent, MD,c

Brian W. McCrindle, MD, MPH,b and Kirk Kanter, MDa

B k d L i ht i t bl i h d i k f t f t lit ft it l di Gi thConclusions: In a large single-center series, low weight continues to be associated with increased earlymortality risk and resource utilization after palliative and corrective cardiac surgery. The hazard of death inlow-weight patientscontinuesbeyond the perioperativeperiod for at least 1 year before normalizing. Strategiesto improve outcomes for this high-risk population must address perioperativecare, outpatient surveillance, andmanagement. (J Thorac Cardiovasc Surg 2014;148:2508-14)

Outcomes of cardiac surgery in patients weighing< 2.5 kg: Affectof patient-dependent and -independent var iables

David Kalfa, MD, PhD,a Ganga Krishnamurthy, MD,b Jennifer Duchon, MD,b Marc Najjar, MD,a

Stephanie Levasseur, MD,c Paul Chai, MD,aJonathan Chen, MD,d Jan Quaegebeur, MD, PhD,aandEmile Bacha, MDa

Results: Hospital mortality in group 1 was 10.9% (n ¼ 16) versus 4.8% (n ¼ 30) in group 2 (P ¼ .007). Thepostoperative length of stay and early unplanned reintervention rate were similar between the 2 groups. Latemortality in group 1 was0.7% (n ¼ 1). In group 1, early outcomeswere independent of theSTAT risk category,uni/biventricular pathway, or surgical timing compared with group 2. A lower gestational age at birth was anindependent risk factor for early mortality in group 1.

Conclusions: A dedicated multidisciplinary neonatal cardiac program can yield good outcomes for neonatesandinfantsweighing< 2.5kgindependently of theSTATrisk categoryanduni/biventricular pathway.A lowergestationalageat birth wasan independent risk factor for hospital mortality. (JThorac Cardiovasc Surg 2014;148:2499-506)

Birth Before39Weeks’ Gestation Is Associated WithWorseOutcomes in Neonates With Heart Disease

abstractBACKGROUND: Recent studies haverevealed increased morbidityandmortality rates in termneonates without birthdefects whoweredeliv-ered before39weeks of completed gestation. Wesought todetermineif asimilar association exists between gestational ageat deliveryandadverse outcomes in neonates with critical congenital heart disease,with particular interest in thoseborn at 37 to38weeks’ gestation.

PATIENTS ANDMETHODS: We studied 971 consecutive neonates whohadcritical congenital heart diseaseandaknown gestational ageandwereadmitted toour cardiac ICUfrom2002through 2008.Gestationalage was stratified into 5groups: 41, 39 to 40, 37 to 38, 34 to 36, and

34completed weeks. Multivariate logistic regression analyses wereused to evaluate mortality and a composite morbidity variable. Multi-variate Poisson regression was used to evaluate duration of ventila-tion, intensive care, and hospitalization.

RESULTS: Compared with the referent group of neonates who weredelivered at 39to40completed weeks’ gestation, neonates born at 37to38weekshad increased mortality (6.9%vs2.6%;adjusted P .049)and morbidity (49.7%vs 39.7%; adjusted P .02) rates and tended torequirealonger durationof mechanical ventilation (adjusted P .05).Patients born after 40 or before 37 weeks also had greater adjustedmortality rates, and those born before 37 weeks had increased mor-bidity rates and required more days of mechanical ventilation andintensivecare.

CONCLUSIONS: For neonates with critical congenital heart disease,deliverybefore39weeks’ gestation isassociated with greater mortal-ityandmorbidity ratesandmoreresourceuse.With respect toneona-tal mortality, the ideal gestational age for delivery of these patientsmaybe39to40completed weeks. Pediatrics 2010;126:e277–e284

AUTHORS: John M. Costello, MD, MPH,aAngelo Polito, MDMPH,a,bDavid W. Brown, MD,aThomas F. McElrath, MD,PhD,cDionne A. Graham, PhD,dRavi R. Thiagarajan, MBBS,MPH,aEmile A. Bacha, MD,eCatherine K. Allan, MD,a

Jennifer N. Cohen, MD,f and Peter C. Laussen, MBBSa

Complexity: Orders


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Complexity: Monitors

• EKG

• Respiratory

• Pulse oximetry

• Cerebral / Somatic oximetry (NIRS)

• Hemodynamic transducer

Complexity: Equipment

• Warmer / Isolette / Crib / Bed / Scale(s)

• Medical Gasses / Gas Tanks

• Resuscitation cart / Defibrillator

• BAIR Hugger / Cooling blanket

• Pyxis® system / Tube system

• Feeding pumps

• Infusion pumps – Alaris® / Medfusion®

Complexity: Machines

• Computers – EMR / EPOE / Radiology / Echo

• EKG / Telemetry

• Respiratory care – Ventilators / HFNC / NC

• Blood Gas / Glucometer / Stuff in Main Labs

• External temporary pacemakers

• Portable ultrasound

• Echocardiogram

• ECLS – CPB / ECMO

• Dialysis

Complexity: Data• Vital Signs and Hemodynamics• I/O and Weight• SpO2 / SmvO2• Blood gases• Blood chemistry• CBC / Coag’s / TEG• BNP• Pre‐Albumin / Albumin• CXR• EKG• Echo / Cath data “interpretation”

Complexity: “Procedures” v. “Guidelines”

• Medication delivery

• ETT suctioning

• Ventilator alarm parameters

• Maintenance of “stuff”:

Arterial catheter, Central venous catheter, PICC, PIV, ETT, Chest drain, NG/OG, Foley, Restraint

• Drawing blood – PAL vs. CVC

• Blood administration – source: bank vs. patient

• Housekeeping• Unit assistants• Therapists – OT / PT / ST• Dieticians• Pharmacists• Respiratory Therapists• Nurses• Care coordinator / Social worker• Physician Assistants / Nurse Practitioners• Physicians – CCM / Cardiology / CT Surgery• Child / Patient‐Family Unit

Complexity: PeopleComplexity: Sentient Beings


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CT‐PA

CCM‐NPNurse

PharmDietician

Care Coord

RT

Pedi Cardiology CT Surgery

Complex

Simple

Simplicity

The “reality” of all that “existed” (was known to be) was composed

of four “elements”.

This “Truth” came to be known across civilizations (cultures).

The School of Athens, Raphael (c 1509)

West East The Four Elements


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The Four Elements

O2

H2O

C6H12O6

ATP

The Four Elements

O2

H2O

C6H12O6

ATP

Simplicity: Oxygen Delivery

O2

ATP

Simple?

C6H12O6 + 6 O2 6 H2O + 6 CO2

© Pearsons Ed

Oxygen Delivery

Cardiac Performance Blood O2 Content

Disclaimer: Original source of the “metaphor” of train and boxcars is unknown to me

Oxygen Delivery

Cardiac Performance


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DO2 ƒ Cardiac Performance + O2 Content

Cardiac Performance

Stroke Volume

Heart Rate

Preload

Afterload

Contractility

Relaxation


Cardiac Performance – Right vs. Left Heart

Disproportionate Preload

Septal Defect

Atrial – RV load

Ventricular – LV load

Disproportionate Afterload

Vascular Resistance

Systemic vs. Pulmonary

Hypertrophy


The RV – the underappreciated V



Afterload Reduction

Diuretics

Inotrope: Digoxin

Volume

Pressure

RV

LV

Digoxin

Digoxin Use Is Associated With Reduced Interstage Mortality in Patients With No History of Arrhythmia After Stage I Palliation for Single Ventricle Heart DiseaseBrown, et al. J Am Heart Assoc (2016)National Pediatric Cardiology Quality Improvement Collaborative

Association of Digoxin With Interstage Mortality: Results From the Pediatric Heart Network Single Ventricle Reconstruction Trial Public Use DatasetOster, et al. J Am Heart Assoc (2016)Pediatric Heart Network Single Ventricle Reconstruction Trial



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Oxygen Delivery

Blood O2 Content


Blood O2 Content

Dissolved

Hgb bound


Blood O2 Content

O2 Capacity – Hgb


Monitoring O2 Delivery

Mixed Venous Oxygen Saturation (SmvO2)

?


Low SmvO2?

Lower O2 supply

Hgb (anemia, hemorrhage)

SaO2 (cyanotic CHD, hypoxia)


Low SmvO2?

Higher O2 demand – sepsis, fever, seizure

1984

Denton, Texas


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Low SmvO2?

Lower Cardiac Output (myocardial, volume)


Monitoring O2 Delivery

Acidemia – blood gas, arterial

Lactemia – lactic acid

Growth?


Monitoring Cardiac Performance

Mixed Venous Oxygen Saturation (SmvO2)

BNP

“Follow Trend”


Near Infra‐Red Spectroscopy as proxy for SmvO2

“Trend”

“past performance does not necessarily predict future results” – brought to you by the SEC

Marketwatch.com


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B‐type Natriuretic Peptide (BNP)

C6H12O6 + 6 O2 6 H2O + 6 CO2

ATP

In Out

The End


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Assessing Cardiac Performance

Preload – CVP

Afterload – BP; skin; Echo

Contractility – ??

Diastolic Relaxation – Echo

Rhythm – EKG monitoring



Low SmvO2

Lower O2 supply

Hgb (anemia, hemorrhage)

SaO2 (cyanotic CHD, hypoxia)

Lower Cardiac Output (myocardial, volume)

Higher O2 demand – sepsis, fever, seizure

Documents

Pediatric Grand Rounds University TX Health 2/05/2016 ... · Science Center at San Antonio ... adverse outcomes in neonates with critical congenital heart disease, ... Pediatric Heart