3 results
Variation in care for children undergoing the Fontan operation for hypoplastic left heart syndrome
- Part of
- Aaron W. Eckhauser, Maria I. Van Rompay, Chitra Ravishankar, Jane W. Newburger, S. Ram Kumar, Christian Pizarro, Nancy Ghanayem, Felicia L. Trachtenberg, Kristin M. Burns, Garick D. Hill, Andrew M. Atz, Michelle S. Hamstra, Mjaye Mazwi, Patsy Park, Marc E. Richmond, Michael Wolf, Jeffrey D. Zampi, Jeffrey P. Jacobs, L. LuAnn Minich, for the Pediatric Heart Network Investigators
-
- Journal:
- Cardiology in the Young / Volume 29 / Issue 12 / December 2019
- Published online by Cambridge University Press:
- 26 November 2019, pp. 1510-1516
-
- Article
- Export citation
-
Background:
The Single Ventricle Reconstruction Trial randomised neonates with hypoplastic left heart syndrome to a shunt strategy but otherwise retained standard of care. We aimed to describe centre-level practice variation at Fontan completion.
Methods:Centre-level data are reported as median or median frequency across all centres and range of medians or frequencies across centres. Classification and regression tree analysis assessed the association of centre-level factors with length of stay and percentage of patients with prolonged pleural effusion (>7 days).
Results:The median Fontan age (14 centres, 320 patients) was 3.1 years (range from 1.7 to 3.9), and the weight-for-age z-score was −0.56 (−1.35 + 0.44). Extra-cardiac Fontans were performed in 79% (4–100%) of patients at the 13 centres performing this procedure; lateral tunnels were performed in 32% (3–100%) at the 11 centres performing it. Deep hypothermic circulatory arrest (nine centres) ranged from 6 to 100%. Major complications occurred in 17% (7–33%). The length of stay was 9.5 days (9–12); 15% (6–33%) had prolonged pleural effusion. Centres with fewer patients (<6%) with prolonged pleural effusion and fewer (<41%) complications had a shorter length of stay (<10 days; sensitivity 1.0; specificity 0.71; area under the curve 0.96). Avoiding deep hypothermic circulatory arrest and higher weight-for-age z-score were associated with a lower percentage of patients with prolonged effusions (<9.5%; sensitivity 1.0; specificity = 0.86; area under the curve 0.98).
Conclusions:Fontan perioperative practices varied widely among study centres. Strategies to decrease the duration of pleural effusion and minimise complications may decrease the length of stay. Further research regarding deep hypothermic circulatory arrest is needed to understand its association with prolonged pleural effusion.
Diagnostic errors in paediatric cardiac intensive care
- Priya N. Bhat, John M. Costello, Ranjit Aiyagari, Paul J. Sharek, Claudia A. Algaze, Mjaye L. Mazwi, Stephen J. Roth, Andrew Y. Shin
-
- Journal:
- Cardiology in the Young / Volume 28 / Issue 5 / May 2018
- Published online by Cambridge University Press:
- 07 February 2018, pp. 675-682
-
- Article
- Export citation
-
Introduction
Diagnostic errors cause significant patient harm and increase costs. Data characterising such errors in the paediatric cardiac intensive care population are limited. We sought to understand the perceived frequency and types of diagnostic errors in the paediatric cardiac ICU.
MethodsPaediatric cardiac ICU practitioners including attending and trainee physicians, nurse practitioners, physician assistants, and registered nurses at three North American tertiary cardiac centres were surveyed between October 2014 and January 2015.
ResultsThe response rate was 46% (N=200). Most respondents (81%) perceived that diagnostic errors harm patients more than five times per year. More than half (65%) reported that errors permanently harm patients, and up to 18% perceived that diagnostic errors contributed to death or severe permanent harm more than five times per year. Medication side effects and psychiatric conditions were thought to be most commonly misdiagnosed. Physician groups also ranked pulmonary overcirculation and viral illness to be commonly misdiagnosed as bacterial illness. Inadequate care coordination, data assessment, and high clinician workload were cited as contributory factors. Delayed diagnostic studies and interventions related to the severity of the patient’s condition were thought to be the most commonly reported process breakdowns. All surveyed groups ranked improving teamwork and feedback pathways as strategies to explore for preventing future diagnostic errors.
ConclusionsPaediatric cardiac intensive care practitioners perceive that diagnostic errors causing permanent harm are common and associated more with systematic and process breakdowns than with cognitive limitations.
Critical care for paediatric patients with heart failure*
- John M. Costello, Mjaye L. Mazwi, Mary E. McBride, Katherine E. Gambetta, Osama Eltayeb, Conrad L. Epting
-
- Journal:
- Cardiology in the Young / Volume 25 / Issue S2 / August 2015
- Published online by Cambridge University Press:
- 17 September 2015, pp. 74-86
-
- Article
- Export citation
-
This review offers a critical-care perspective on the pathophysiology, monitoring, and management of acute heart failure syndromes in children. An in-depth understanding of the cardiovascular physiological disturbances in this population of patients is essential to correctly interpret clinical signs, symptoms and monitoring data, and to implement appropriate therapies. In this regard, the myocardial force–velocity relationship, the Frank–Starling mechanism, and pressure–volume loops are discussed. A variety of monitoring modalities are used to provide insight into the haemodynamic state, clinical trajectory, and response to treatment. Critical-care treatment of acute heart failure is based on the fundamental principles of optimising the delivery of oxygen and minimising metabolic demands. The former may be achieved by optimising systemic arterial oxygen content and the variables that determine cardiac output: heart rate and rhythm, preload, afterload, and contractility. Metabolic demands may be decreased by a number of ways including positive pressure ventilation, temperature control, and sedation. Mechanical circulatory support should be considered for refractory cases. In the near future, monitoring modalities may be improved by the capture and analysis of complex clinical data such as pressure waveforms and heart rate variability. Using predictive modelling and streaming analytics, these data may then be used to develop automated, real-time clinical decision support tools. Given the barriers to conducting multi-centre trials in this population of patients, the thoughtful analysis of data from multi-centre clinical registries and administrative databases will also likely have an impact on clinical practice.