Improving outcomes & quality through collaboration

Mechanical ventilation is common in critically ill children with cardiac disease, but literature focused on ventilator liberation practices for this unique pediatric subpopulation is limited. We aimed to describe current ventilator liberation practices in critically ill children with cardiac disease. Through the Pediatric Cardiac Critical Care Consortium, an electronic survey was distributed to pediatric ICU attending physicians caring for patients with cardiac disease evaluating institutional protocols and individual practices around ventilator liberation including criteria for extubation readiness testing (ERT), ERT components, spontaneous breathing trial (SBT) method and duration, timing of extubation, and postextubation respiratory support. We received 133 responses representing 47 hospitals. ERT eligibility screening and SBT protocols were reported at 22 (47%) and 26 (55%) of the 47 institutions, respectively. Most respondents used SBTs in their assessment of extubation readiness (95%) and pressure support augmentation to CPAP for SBT (92%). Most respondents reported a maximum dose threshold for epinephrine (81%), above which they would not extubate. Some indices used for determination of extubation readiness were used by nearly all respondents: pulse oximetry (92%), serum lactate (86%), and arterial pH (85%); but some respondents also report using mixed venous saturation (68%), ventricular function (62%), near-infrared spectroscopy (62%), and systemic atrioventricular valve regurgitation (53%). Reported use of noninvasive respiratory support (NRS) after extubation was common, up to 90% in selected subgroups. There was wide variation in the type of NRS used in all populations. ERT eligibility screening and SBT protocols were reported in only half of the institutions surveyed, and notable variation exists between parameters surrounding extubation readiness assessment and postextubation respiratory support. These data suggest opportunities to increase protocol development to align with established clinical practice guidelines around ERT and conduct multi-center quality improvement to identify best practices for ventilator liberation in this patient population.

Racial and ethnic disparities in neonatal postoperative outcomes are reported, but differences in cardiac surgery-associated acute kidney injury (CS-AKI) remain unexamined. We assessed racial/ethnic disparities in CS-AKI prevalence and outcomes in neonates undergoing congenital heart surgery.

ObjectiveChildren's HeartLink and the University of California San Francisco (UCSF) have partnered with Vietnam National Children's Hospital (VNCH). Compared with low- and middle-income countries (LMICs) enrolled in the International Quality Improvement Collaborative for Congenital Heart Disease, VNCH is a high performing center. Our goal is to compare outcomes of VNCH with North American centers leveraging data from the Pediatric Cardiac Critical Care Consortium (PC) in 2023.MethodsChildren's HeartLink established a partnership with VNCH in 2017 with a consistent senior-level medical volunteer team from UCSF (Dr Sano currently at Showa University Hospital) engaged in semiannual training visits and weekly case conferences. In-person visits have evolved to hands-off teaching. Areas of improvement are identified, and outcomes presented at the subsequent visit. International Quality Improvement Collaborative and PC perform site specific audits to confirm data accuracy. Data presented are based on primary operations. Conversion from Risk Adjustment for Congenital Heart Surgery (RACHS-1) to STAT is as follows: RACHS-1 1-4 equal STAT 1-4; RACHS-1 5-6 equal STAT 5.ResultsResults represent 8 on-site visits and 109 case discussions. VNCH performed 1,056 operations, and PC represents 14,506 operations in 2023. VNCH had comparable outcomes, except higher surgical mortality for infants with prematurity and noncardiac abnormalities, and a higher rate of surgical site infections. VNCH performed fewer operations on patients with noncardiac abnormalities and higher STAT scores.ConclusionsPartnership of highly resourced North American programs with underresourced LMIC centers can elevate congenital heart surgery outcomes. VNCH is a high-volume center with respectable outcomes. Future focus will be higher STAT level and neonatal surgeries.

ObjectiveThis study aimed to investigate associations between early diuretic administration following neonatal cardiac surgery and clinical outcomes.MethodsThis was a retrospective cohort study including neonates who underwent cardiac surgery within the first 30 postnatal days between September 2015 and January 2018 at 22 centers participating in the Pediatric Cardiac Critical Care Consortium (PC) and Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) registries. Multivariable logistic and ordinal regression models were used to assess associations between early diuretic administration [defined as receipt of furosemide in the operating room and/or any diuretic on postoperative day 0 (POD0)] and outcomes. Outcomes: peak cumulative fluid balance, delay in achieving first negative daily fluid balance, duration of mechanical ventilation, hospital length of stay (LOS), and severe persistent acute kidney injury (AKI). An additional exploratory analysis was performed to assess for association between receiving enteral diuretic within the study period (POD0-6) and hospital LOS.ResultsOf 2240 neonates, 63% (n = 1405) had early diuretic administration and 15% (n = 344) received enteral diuretics. After adjusting for covariates and center effect, early diuretic administration was associated with shorter duration of mechanical ventilation [Odds Ratio (OR) = 0.59, 95% confidence interval (95%CI) 0.42-0.82] and a lower odds of delay in negative daily fluid balance (OR = 0.44, 95%CI 0.26-0.75), but not severe persistent AKI. Receiving enteral diuretic by POD6 was associated with decreased hospital LOS (OR = 0.3, 95%CI 0.23-0.41).ConclusionsEarly diuretic administration is associated with earlier time to negative daily fluid balance and shorter duration of mechanical ventilation. Efforts to standardize early diuretic administration have the potential to decrease resource utilization and warrants further study.

Unplanned cardiac reinterventions after congenital cardiac surgery may complicate the postoperative course. We sought to identify incidence rates and risk factors for unplanned cardiac reinterventions and associations between unplanned cardiac reinterventions and hospital mortality.