Objective
To determine whether a collaborative learning strategy derived clinical practice guideline (CPG) can reduce the duration of endotracheal intubation following infant heart surgery.
Design
Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre- and post-CPG implementation at the four sites participating in the collaborative (active sites) compared to data from five PHN centers not participating in collaborative learning (control sites).
Patients
Data were collected for infants following 2 index operations: 1) repair of isolated coarctation of the aorta (birth-365 days) and 2) repair of tetralogy of Fallot (29–365 days). There were 240 subjects eligible for the CPG at active sites and 259 subjects at control sites.
Measurements and Main Results
After CPG implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p<0.001) with no increase in reintubation rate. The median duration of post-operative intubation among active sites decreased from 21.2 hours to 4.5 hours (p<.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p=0.63). At active sites CPG implementation had no statistically significant impact on median intensive care unit (ICU) length of stay (LOS) (71.9 hours pre- vs. 69.2 post-implementation, p=0.29) for the entire cohort. There was a trend toward shorter ICU LOS in the tetralogy of Fallot subgroup (71.6 hours pre- vs. 54.2 post-implementation, p=0.068).
Conclusions
A collaborative learning strategy designed CPG significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation CPG did not significantly change post-operative ICU LOS.
Capillary blood gases accurately reflect arterial pH and PCO2 in most pediatric intensive care unit patients. Capillary samples did not significantly underestimate arterial hypercarbia or acidosis. This conservative reflection of metabolic status may be particularly useful in hemodynamically stable patients with mild-to-moderate lung disease.
NMB significantly reduces oxygen consumption and energy expenditure in critically ill children who are sedated and mechanically ventilated; the degree of reduction is small.
Distribution and elimination kinetics of bumetanide were similar in all patients. Elimination kinetics were first order over the dose range of 0.005 to 0.10 mg/kg. Pharmacokinetic parameter estimates (beta volume of distribution, volume of distribution at steady state, clearance, renal clearance, half-life, and mean residence time) were independent of the dose of bumetanide administered. Single doses of bumetanide up to 0.10 mg/kg appear to be well tolerated in acutely ill volume-overloaded infants aged 0 to 6 months.
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