Pediatric Grand Rounds University TX Health 2/05/2016 ... · Science Center at San Antonio ......
Transcript of Pediatric Grand Rounds University TX Health 2/05/2016 ... · Science Center at San Antonio ......
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?
Pediatric Grand Rounds ‐ University of TX Health Science Center at San Antonio
2/05/2016
2
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
Pediatric Grand Rounds ‐ University of TX Health Science Center at San Antonio
2/05/2016
3
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
Pediatric Grand Rounds ‐ University of TX Health Science Center at San Antonio
2/05/2016
4
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
Pediatric Grand Rounds ‐ University of TX Health Science Center at San Antonio
2/05/2016
5
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
Pediatric Grand Rounds ‐ University of TX Health Science Center at San Antonio
2/05/2016
6
DO2 ƒ Cardiac Performance + O2 Content
Cardiac Performance
Stroke Volume
Heart Rate
Preload
Afterload
Contractility
Relaxation
DO2 ƒ Cardiac Performance + O2 Content
Cardiac Performance – Right vs. Left Heart
Disproportionate Preload
Septal Defect
Atrial – RV load
Ventricular – LV load
Disproportionate Afterload
Vascular Resistance
Systemic vs. Pulmonary
Hypertrophy
DO2 ƒ Cardiac Performance + O2 Content
The RV – the underappreciated V
DO2 ƒ Cardiac Performance + O2 Content
DO2 ƒ Cardiac Performance + O2 Content
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
DO2 ƒ Cardiac Performance + O2 Content
Pediatric Grand Rounds ‐ University of TX Health Science Center at San Antonio
2/05/2016
7
Oxygen Delivery
Blood O2 Content
DO2 ƒ Cardiac Performance + O2 Content
Blood O2 Content
Dissolved
Hgb bound
DO2 ƒ Cardiac Performance + O2 Content
Blood O2 Content
O2 Capacity – Hgb
DO2 ƒ Cardiac Performance + O2 Content
Monitoring O2 Delivery
Mixed Venous Oxygen Saturation (SmvO2)
?
DO2 ƒ Cardiac Performance + O2 Content
Low SmvO2?
Lower O2 supply
Hgb (anemia, hemorrhage)
SaO2 (cyanotic CHD, hypoxia)
DO2 ƒ Cardiac Performance + O2 Content
Low SmvO2?
Higher O2 demand – sepsis, fever, seizure
1984
Denton, Texas
Pediatric Grand Rounds ‐ University of TX Health Science Center at San Antonio
2/05/2016
8
DO2 ƒ Cardiac Performance + O2 Content
Low SmvO2?
Lower Cardiac Output (myocardial, volume)
DO2 ƒ Cardiac Performance + O2 Content
Monitoring O2 Delivery
Acidemia – blood gas, arterial
Lactemia – lactic acid
Growth?
DO2 ƒ Cardiac Performance + O2 Content
Monitoring Cardiac Performance
Mixed Venous Oxygen Saturation (SmvO2)
BNP
“Follow Trend”
DO2 ƒ Cardiac Performance + O2 Content
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
Pediatric Grand Rounds ‐ University of TX Health Science Center at San Antonio
2/05/2016
9
DO2 ƒ Cardiac Performance + O2 Content
B‐type Natriuretic Peptide (BNP)
C6H12O6 + 6 O2 6 H2O + 6 CO2
ATP
In Out
The End
Pediatric Grand Rounds ‐ University of TX Health Science Center at San Antonio
2/05/2016
10
Assessing Cardiac Performance
Preload – CVP
Afterload – BP; skin; Echo
Contractility – ??
Diastolic Relaxation – Echo
Rhythm – EKG monitoring
DO2 ƒ Cardiac Performance + O2 Content
DO2 ƒ Cardiac Performance + O2 Content
Low SmvO2
Lower O2 supply
Hgb (anemia, hemorrhage)
SaO2 (cyanotic CHD, hypoxia)
Lower Cardiac Output (myocardial, volume)
Higher O2 demand – sepsis, fever, seizure