Pediatric delirium is associated with increased risk of mortality, prolonged time to extubation, ... more Pediatric delirium is associated with increased risk of mortality, prolonged time to extubation, and increased length of stay. If the risk of delirium could be identified early, then preventative strategies could be targeted. Therefore, we studied the performance of an early delirium prediction model in children admitted to a pediatric cardiac intensive care unit using variables extracted from the electronic medical record 24 h after admission. This single center, retrospective study extracted the presence of fifteen previously defined variables associated with delirium in children to create a model to predict the risk of delirium anytime during a child's stay. Delirium was considered present if a patient had at least one Cornell Assessment of Pediatric Delirium score of 9 or greater, required an antipsychotic or had an ICD-10 diagnosis of delirium. Repeated measures logistic regression between the preselected variables associated with delirium and the clinical diagnosis of deli...
Critical Care of Children with Heart Disease, 2009
This chapter concentrates on general aspects of the classification and physiology of the single v... more This chapter concentrates on general aspects of the classification and physiology of the single ventricle. Specific chapters in this book are dedicated to anoma-lies with single ventricle physiology, like the hypoplas-tic left and right syndrome (ie, chapters 22 and 30). Single ...
BACKGROUND Infants with congenital heart disease (CHD) may exhibit increased metabolic demands, a... more BACKGROUND Infants with congenital heart disease (CHD) may exhibit increased metabolic demands, and many will undergo placement of a gastrostomy to achieve adequate nutritional intake. There is a paucity of data, however, comparing the operative risks and overall complications of gastrostomy placement in cyanotic versus acyanotic infants with CHD. We hypothesized that patients with cyanotic CHD would have a higher rate of gastrostomy-associated complications than infants with acyanotic CHD. METHODS We retrospectively reviewed patients who underwent gastrostomy button placement after cardiac surgery for CHD between 2013 and 2018. Patients were stratified into cyanotic CHD and acyanotic CHD cohorts. Patient data were extracted from the Society of Thoracic Surgeons database and merged with clinical data related to gastrostomy placement and complications from chart review. Unadjusted analyses were used to find covariates associated with cyanotic CHD and acyanotic CHD, using a t-test or ...
Infants with CHD are at increased risk of necrotising enterocolitis, which can interfere with the... more Infants with CHD are at increased risk of necrotising enterocolitis, which can interfere with the achievement of adequate nutrition and, ultimately, growth and development. Necrotising enterocolitis is classified by severity as suspected, confirmed, and advanced. We sought to quantify the incidence of all types of necrotising enterocolitis among infants who underwent surgery, with a particular focus on suspected necrotising enterocolitis. This is a retrospective review of all infants <6 months of age who underwent cardiac surgery during 2012 and 2013 at Children’s Hospital Colorado. We examined the hospital course of 265 hospitalisations (n=251 patients) and found 18 patients (19 hospitalisations) with suspected necrotising enterocolitis and 16 patients (16 hospitalisations) with confirmed or advanced necrotising enterocolitis. Single-ventricle physiology, lower weight, and younger age were associated with necrotising enterocolitis. Patients with all types of necrotising enteroco...
Variable compliance to postoperative feeding algorithms after pediatric cardiac surgery may be as... more Variable compliance to postoperative feeding algorithms after pediatric cardiac surgery may be associated with suboptimal growth, decreased parental satisfaction, and prolonged hospital length of stay (LOS). Our heart center performed an audit of compliance to a previously introduced postoperative feeding algorithm to guide quality improvement efforts. We hypothesized that algorithm noncompliance would be associated with increased LOS. We retrospectively identified children ≤ 3 months admitted for their first cardiac surgery between January 1, 2015 and December 31, 2016. The algorithm uses objective oral feeding readiness assessments (FRA). At the end of a predefined evaluation period, a "sentinel" FRA score is assigned. The sentinel FRA and FRA trend guide decisions to pursue gastrostomy tube (GT) or oral-only feeds. Among those who reached the sentinel FRA, we defined compliance as ≤ 3 days before pursuing GT or oral-only feeds once indicated by the algorithm. Sixty-nine...
World journal for pediatric & congenital heart surgery, Nov 1, 2018
Ketorolac is used for pediatric analgesia after surgery despite its known platelet inhibition via... more Ketorolac is used for pediatric analgesia after surgery despite its known platelet inhibition via the arachidonic acid (AA) pathway. The degree of platelet inhibitory effect after cardiac surgery is not well characterized. Thromboelastography with platelet mapping (TEG-PM) is emerging as a frequently used test to evaluate platelet inhibition via the AA pathway. Post hoc analysis of a data set collected in a prospective observational cohort study evaluating platelet inhibition in children after congenital heart surgery with cardiopulmonary bypass (CPB). Categorization into two groups: (1) received ketorolac and (2) did not receive ketorolac for analgesia after surgery. The TEG-PM was evaluated at two time points (prior to surgery and 12-48 hours after CPB). Fifty-three children were studied; mean age was 6.6 (range: 0.07-16.7) years and 45% (n = 24) were female. Participants were distributed into two groups by ketorolac use, 41 within the ketorolac group and 12 in the no ketorolac gr...
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, Jan 15, 2018
To assess if morphine pharmacokinetics are different in children with Down syndrome when compared... more To assess if morphine pharmacokinetics are different in children with Down syndrome when compared with children without Down syndrome. Prospective single-center study including subjects with Down syndrome undergoing cardiac surgery (neonate to 18 yr old) matched by age and cardiac lesion with non-Down syndrome controls. Subjects were placed on a postoperative morphine infusion that was adjusted as clinically necessary, and blood was sampled to measure morphine and its metabolites concentrations. Morphine bolus dosing was used as needed, and total dose was tracked. Infusions were continued for 24 hours or until patients were extubated, whichever came first. Postinfusion, blood samples were continued for 24 hours for further evaluation of kinetics. If patients continued to require opioid, a nonmorphine alternative was used. Morphine concentrations were determined using a unique validated liquid chromatography tandem-mass spectrometry assay using dried blood spotting as opposed to larg...
Feeding practices after neonatal and congenital heart surgery are complicated and variable, which... more Feeding practices after neonatal and congenital heart surgery are complicated and variable, which may be associated with prolonged hospitalization length of stay (LOS). Systematic assessment of feeding skills after cardiac surgery may earlier identify those likely to have protracted feeding difficulties, which may promote standardization of care. Neonates and infants ≤3 months old admitted for their first cardiac surgery were retrospectively identified during a 1-year period at a single center. A systematic feeding readiness assessment (FRA) was utilized to score infant feeding skills. FRA scores were assigned immediately prior to surgery and 1, 2, and 3 weeks after surgery. FRA scores were analyzed individually and in combination as predictors of gastrostomy tube (GT) placement prior to hospital discharge by logistic regression. Eighty-six patients met inclusion criteria and 69 patients had complete data to be included in the final model. The mean age of admit was five days and 51%...
To determine incidence, associated risk factors, and characteristics of delirium in a pediatric c... more To determine incidence, associated risk factors, and characteristics of delirium in a pediatric cardiac intensive care unit (CICU). Delirium is a frequent and serious complication in adults after cardiac surgery, but there is limited understanding of its impact in children with critical cardiac disease. Single-center prospective observational study of CICU patients ≤21 years old. All were screened for delirium using the Cornell Assessment for Pediatric Delirium each 12-hour shift. Ninety-nine patients were included. Incidence of delirium was 57%. Median time to development of delirium was 1 day (95% CI 0, 1 days). Children with delirium were younger (geometric mean age 4 vs 46 months; P < .001), had longer periods of mechanical ventilation (mean 35.9 vs 8.8 hours; P = .002) and had longer cardiopulmonary bypass times (geometric mean 126 vs 81 minutes; P = .001). Delirious patients had longer length of CICU stay than those without delirium (median 3 (IQR 2, 12.5) vs 1 (IQR1, 2) da...
Topical anesthetics are commonly used in many health care settings and for many clinical conditio... more Topical anesthetics are commonly used in many health care settings and for many clinical conditions. However, there are a number of potential adverse effects associated with their use. Their widespread administration can convey a false sense of security and failure to appreciate possible complications. We present the case of an infant with extensive vascular malformations treated with EMLA cream who developed seizures and methemoglobinemia from lidocaine and prilocaine toxicity. We describe the pathophysiology of these morbidities, the use of pulse oximetry in this setting, and the clinical presentation and treatment of methemoglobinemia.
Purpose: Tachyarrhythmias are common following repair of congenital heart disease, and may be ass... more Purpose: Tachyarrhythmias are common following repair of congenital heart disease, and may be associated with increased morbidity and mortality. The purpose of this study was to determine the incidence of tachyarrhythmia in patients following Norwood operation. Methods: Retrospective chart review of all patients who underwent stage I Norwood procedure from 1/1/2003 to 9/1/2011 (n=100). Data collected included demographics, shunt type (modified Blalock-Taussig shunt (mBTS) or right ventricle to pulmonary artery conduit (RVPA), surgical variables, type of tachycardia, interval since surgery, cycle length, and need for antiarrhythmic medication at discharge. Results: Data regarding arrhythmia was available for 98 patients. Tachyarrhythmia occurred in 33/98 patients (34%). Six patients with a tachyarrhythmia died. Causes of mortality in those with a tachycardia included cardiac arrest (n=2) or circulatory collapse requiring ECMO (n=2), respiratory arrest (n=1) and dural sinus venous thr...
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2014
Pediatric delirium is associated with increased risk of mortality, prolonged time to extubation, ... more Pediatric delirium is associated with increased risk of mortality, prolonged time to extubation, and increased length of stay. If the risk of delirium could be identified early, then preventative strategies could be targeted. Therefore, we studied the performance of an early delirium prediction model in children admitted to a pediatric cardiac intensive care unit using variables extracted from the electronic medical record 24 h after admission. This single center, retrospective study extracted the presence of fifteen previously defined variables associated with delirium in children to create a model to predict the risk of delirium anytime during a child's stay. Delirium was considered present if a patient had at least one Cornell Assessment of Pediatric Delirium score of 9 or greater, required an antipsychotic or had an ICD-10 diagnosis of delirium. Repeated measures logistic regression between the preselected variables associated with delirium and the clinical diagnosis of deli...
Critical Care of Children with Heart Disease, 2009
This chapter concentrates on general aspects of the classification and physiology of the single v... more This chapter concentrates on general aspects of the classification and physiology of the single ventricle. Specific chapters in this book are dedicated to anoma-lies with single ventricle physiology, like the hypoplas-tic left and right syndrome (ie, chapters 22 and 30). Single ...
BACKGROUND Infants with congenital heart disease (CHD) may exhibit increased metabolic demands, a... more BACKGROUND Infants with congenital heart disease (CHD) may exhibit increased metabolic demands, and many will undergo placement of a gastrostomy to achieve adequate nutritional intake. There is a paucity of data, however, comparing the operative risks and overall complications of gastrostomy placement in cyanotic versus acyanotic infants with CHD. We hypothesized that patients with cyanotic CHD would have a higher rate of gastrostomy-associated complications than infants with acyanotic CHD. METHODS We retrospectively reviewed patients who underwent gastrostomy button placement after cardiac surgery for CHD between 2013 and 2018. Patients were stratified into cyanotic CHD and acyanotic CHD cohorts. Patient data were extracted from the Society of Thoracic Surgeons database and merged with clinical data related to gastrostomy placement and complications from chart review. Unadjusted analyses were used to find covariates associated with cyanotic CHD and acyanotic CHD, using a t-test or ...
Infants with CHD are at increased risk of necrotising enterocolitis, which can interfere with the... more Infants with CHD are at increased risk of necrotising enterocolitis, which can interfere with the achievement of adequate nutrition and, ultimately, growth and development. Necrotising enterocolitis is classified by severity as suspected, confirmed, and advanced. We sought to quantify the incidence of all types of necrotising enterocolitis among infants who underwent surgery, with a particular focus on suspected necrotising enterocolitis. This is a retrospective review of all infants <6 months of age who underwent cardiac surgery during 2012 and 2013 at Children’s Hospital Colorado. We examined the hospital course of 265 hospitalisations (n=251 patients) and found 18 patients (19 hospitalisations) with suspected necrotising enterocolitis and 16 patients (16 hospitalisations) with confirmed or advanced necrotising enterocolitis. Single-ventricle physiology, lower weight, and younger age were associated with necrotising enterocolitis. Patients with all types of necrotising enteroco...
Variable compliance to postoperative feeding algorithms after pediatric cardiac surgery may be as... more Variable compliance to postoperative feeding algorithms after pediatric cardiac surgery may be associated with suboptimal growth, decreased parental satisfaction, and prolonged hospital length of stay (LOS). Our heart center performed an audit of compliance to a previously introduced postoperative feeding algorithm to guide quality improvement efforts. We hypothesized that algorithm noncompliance would be associated with increased LOS. We retrospectively identified children ≤ 3 months admitted for their first cardiac surgery between January 1, 2015 and December 31, 2016. The algorithm uses objective oral feeding readiness assessments (FRA). At the end of a predefined evaluation period, a "sentinel" FRA score is assigned. The sentinel FRA and FRA trend guide decisions to pursue gastrostomy tube (GT) or oral-only feeds. Among those who reached the sentinel FRA, we defined compliance as ≤ 3 days before pursuing GT or oral-only feeds once indicated by the algorithm. Sixty-nine...
World journal for pediatric & congenital heart surgery, Nov 1, 2018
Ketorolac is used for pediatric analgesia after surgery despite its known platelet inhibition via... more Ketorolac is used for pediatric analgesia after surgery despite its known platelet inhibition via the arachidonic acid (AA) pathway. The degree of platelet inhibitory effect after cardiac surgery is not well characterized. Thromboelastography with platelet mapping (TEG-PM) is emerging as a frequently used test to evaluate platelet inhibition via the AA pathway. Post hoc analysis of a data set collected in a prospective observational cohort study evaluating platelet inhibition in children after congenital heart surgery with cardiopulmonary bypass (CPB). Categorization into two groups: (1) received ketorolac and (2) did not receive ketorolac for analgesia after surgery. The TEG-PM was evaluated at two time points (prior to surgery and 12-48 hours after CPB). Fifty-three children were studied; mean age was 6.6 (range: 0.07-16.7) years and 45% (n = 24) were female. Participants were distributed into two groups by ketorolac use, 41 within the ketorolac group and 12 in the no ketorolac gr...
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, Jan 15, 2018
To assess if morphine pharmacokinetics are different in children with Down syndrome when compared... more To assess if morphine pharmacokinetics are different in children with Down syndrome when compared with children without Down syndrome. Prospective single-center study including subjects with Down syndrome undergoing cardiac surgery (neonate to 18 yr old) matched by age and cardiac lesion with non-Down syndrome controls. Subjects were placed on a postoperative morphine infusion that was adjusted as clinically necessary, and blood was sampled to measure morphine and its metabolites concentrations. Morphine bolus dosing was used as needed, and total dose was tracked. Infusions were continued for 24 hours or until patients were extubated, whichever came first. Postinfusion, blood samples were continued for 24 hours for further evaluation of kinetics. If patients continued to require opioid, a nonmorphine alternative was used. Morphine concentrations were determined using a unique validated liquid chromatography tandem-mass spectrometry assay using dried blood spotting as opposed to larg...
Feeding practices after neonatal and congenital heart surgery are complicated and variable, which... more Feeding practices after neonatal and congenital heart surgery are complicated and variable, which may be associated with prolonged hospitalization length of stay (LOS). Systematic assessment of feeding skills after cardiac surgery may earlier identify those likely to have protracted feeding difficulties, which may promote standardization of care. Neonates and infants ≤3 months old admitted for their first cardiac surgery were retrospectively identified during a 1-year period at a single center. A systematic feeding readiness assessment (FRA) was utilized to score infant feeding skills. FRA scores were assigned immediately prior to surgery and 1, 2, and 3 weeks after surgery. FRA scores were analyzed individually and in combination as predictors of gastrostomy tube (GT) placement prior to hospital discharge by logistic regression. Eighty-six patients met inclusion criteria and 69 patients had complete data to be included in the final model. The mean age of admit was five days and 51%...
To determine incidence, associated risk factors, and characteristics of delirium in a pediatric c... more To determine incidence, associated risk factors, and characteristics of delirium in a pediatric cardiac intensive care unit (CICU). Delirium is a frequent and serious complication in adults after cardiac surgery, but there is limited understanding of its impact in children with critical cardiac disease. Single-center prospective observational study of CICU patients ≤21 years old. All were screened for delirium using the Cornell Assessment for Pediatric Delirium each 12-hour shift. Ninety-nine patients were included. Incidence of delirium was 57%. Median time to development of delirium was 1 day (95% CI 0, 1 days). Children with delirium were younger (geometric mean age 4 vs 46 months; P < .001), had longer periods of mechanical ventilation (mean 35.9 vs 8.8 hours; P = .002) and had longer cardiopulmonary bypass times (geometric mean 126 vs 81 minutes; P = .001). Delirious patients had longer length of CICU stay than those without delirium (median 3 (IQR 2, 12.5) vs 1 (IQR1, 2) da...
Topical anesthetics are commonly used in many health care settings and for many clinical conditio... more Topical anesthetics are commonly used in many health care settings and for many clinical conditions. However, there are a number of potential adverse effects associated with their use. Their widespread administration can convey a false sense of security and failure to appreciate possible complications. We present the case of an infant with extensive vascular malformations treated with EMLA cream who developed seizures and methemoglobinemia from lidocaine and prilocaine toxicity. We describe the pathophysiology of these morbidities, the use of pulse oximetry in this setting, and the clinical presentation and treatment of methemoglobinemia.
Purpose: Tachyarrhythmias are common following repair of congenital heart disease, and may be ass... more Purpose: Tachyarrhythmias are common following repair of congenital heart disease, and may be associated with increased morbidity and mortality. The purpose of this study was to determine the incidence of tachyarrhythmia in patients following Norwood operation. Methods: Retrospective chart review of all patients who underwent stage I Norwood procedure from 1/1/2003 to 9/1/2011 (n=100). Data collected included demographics, shunt type (modified Blalock-Taussig shunt (mBTS) or right ventricle to pulmonary artery conduit (RVPA), surgical variables, type of tachycardia, interval since surgery, cycle length, and need for antiarrhythmic medication at discharge. Results: Data regarding arrhythmia was available for 98 patients. Tachyarrhythmia occurred in 33/98 patients (34%). Six patients with a tachyarrhythmia died. Causes of mortality in those with a tachycardia included cardiac arrest (n=2) or circulatory collapse requiring ECMO (n=2), respiratory arrest (n=1) and dural sinus venous thr...
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2014
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