The amount of cardiovascular support in the first 48 hrs after congenital heart surgery with cardiopulmonary bypass predicts eventual morbidity and mortality in young infants. The degree of support is best characterized by a maximum vasoactive-inotropic score obtained during this period. The usefulness of vasoactive-inotropic score as an independent predictor of clinical outcome in infants after cardiac surgery may have important implications for future cardiothoracic intensive care unit research.

BACKGROUND In some studies, tight glycemic control with insulin improved outcomes in adults undergoing cardiac surgery, but these benefits are unproven in critically ill children at risk for hyperinsulinemic hypoglycemia. We tested the hypothesis that tight glycemic control reduces morbidity after pediatric cardiac surgery. METHODS In this two-center, prospective, randomized trial, we enrolled 980 children, 0 to 36 months of age, undergoing surgery with cardiopulmonary bypass. Patients were randomly assigned to either tight glycemic control (with the use of an insulin-dosing algorithm targeting a blood glucose level of 80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) or standard care in the cardiac intensive care unit (ICU). Continuous glucose monitoring was used to guide the frequency of blood glucose measurement and to detect impending hypoglycemia. The primary outcome was the rate of health care–associated infections in the cardiac ICU. Secondary outcomes included mortality, length of stay, organ failure, and hypoglycemia. RESULTS A total of 444 of the 490 children assigned to tight glycemic control (91%) received insulin versus 9 of 490 children assigned to standard care (2%). Although normoglycemia was achieved earlier with tight glycemic control than with standard care (6 hours vs. 16 hours, P<0.001) and was maintained for a greater proportion of the critical illness period (50% vs. 33%, P<0.001), tight glycemic control was not associated with a significantly decreased rate of health care–associated infections (8.6 vs. 9.9 per 1000 patient-days, P = 0.67). Secondary outcomes did not differ significantly between groups, and tight glycemic control did not benefit high-risk subgroups. Only 3% of the patients assigned to tight glycemic control had severe hypoglycemia (blood glucose <40 mg per deciliter [2.2 mmol per liter]). CONCLUSIONS Tight glycemic control can be achieved with a low hypoglycemia rate after cardiac surgery in children, but it does not significantly change the infection rate, mortality, length of stay, or measures of organ failure, as compared with standard care. (Funded by the National Heart, Lung, and Blood Institute and others; SPECS ClinicalTrials.gov number, NCT00443599.)

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Objective To empirically derive the optimal measure of pharmacologic cardiovascular support in infants undergoing cardiac surgery with bypass, and to assess the association between this score and clinical outcomes in a multi-institutional cohort. Design Prospective, multi-institutional cohort study. Setting Cardiac intensive care units (CICU) at 4 academic children’s hospitals participating in the Pediatric Cardiac Critical Care Consortium (PC4) during the study period. Patients Children <1 year of age at the time of surgery treated post-operatively in the CICU. Interventions None Measurements and Main Results Three hundred ninety-one infants undergoing surgery with bypass were enrolled consecutively from 11/2011–4/2012. Hourly doses of all vasoactive agents were recorded for the first 48 hours after CICU admission. Multiple derivations of an inotropic score were tested, and maximum vasoactive-inotropic score (VIS) in the first 24 hours was further analyzed for association with clinical outcomes. The primary composite “poor outcome” variable included at least one of mortality, mechanical circulatory support, cardiac arrest, renal replacement therapy, or neurologic injury. High VIS was empirically defined as ≥20. Multivariable logistic regression was performed controlling for center and patient characteristics. Patients with high VIS had significantly greater odds of a poor outcome [OR 6.5, 95% confidence interval (CI) 2.9–14.6], mortality (OR 13.2, 95% CI 3.7–47.6), time to first extubation, and CICU length of stay compared to patients with low VIS. Stratified analyses by age (neonate vs. infant) and surgical complexity (low vs. high) showed similar associations with increased morbidity and mortality for patients with high VIS. Conclusions Maximum VIS calculated in the first 24 hours after CICU admission was strongly and significantly associated with morbidity and mortality in this multi-institutional cohort of infants undergoing cardiac surgery. Maximum VIS≥20 predicts an increased likelihood of a poor composite clinical outcome. The findings were consistent in stratified analyses by age and surgical complexity.

Objective In pediatric patients fluid overload (FO) at continuous renal replacement (CRRT) initiation is associated with increased mortality. The aim of this study was to characterize the association between fluid overload at CRRT initiation, fluid removal during CRRT, the kinetics of fluid removal and mortality in a large pediatric population receiving CRRT while on extracorporeal membrane oxygenation (ECMO). Design Retrospective chart review. Setting Tertiary children’s hospital Patients ECMO patients requiring CRRT from July 2006 to September 2010 Interventions None Measurements and Main Results Overall ICU survival was 34% for 53 patients that were initiated on CRRT while on ECMO during the study period. Median FO at CRRT initiation was significantly lower in survivors compared to non-survivors (24.5 vs. 38%, p=0.006). Median FO at CRRT discontinuation was significantly lower in survivors compared to non-survivors (7.1 vs. 17.5%, p=0.035). After adjusting for percent FO at CRRT initiation, age and severity of illness, the change in FO at CRRT discontinuation was not significantly associated with mortality (p=0.212). Models investigating the rates of fluid removal in different periods, age, severity of illness and fluid overload at CRRT initiation found that fluid overload at CRRT initiation was the most consistent predictor of survival. Conclusions Our data demonstrates an association between FO at CRRT initiation and mortality in pediatric patients receiving ECMO. The degree of FO at CRRT discontinuation is also associated with mortality, but appears to reflect the effect of FO at initiation. Furthermore, correction of FO to ≤ 10% was not associated with improved survival. These results suggest that intervening prior to the development of significant FO may be more clinically effective than attempting fluid removal after significant fluid overload has developed. Our findings suggest a role for earlier initiation of CRRT in this population, and warrant further clinical studies.

Background Although extracorporeal CPR (E-CPR) can result in survival after failed conventional CPR (C-CPR), no large, systematic comparison of pediatric E-CPR versus continued C-CPR has been reported. Methods and Results Consecutive patients <18 years old with CPR events ≥ 10 minutes duration reported to GWTG-R between January 2000 and December 2011 were identified. Hospitals were grouped by teaching status and location. Primary outcome was survival to discharge. Regression modeling was performed conditioning on hospital groups. A secondary analysis was performed using propensity-score matching. Of 3,756 evaluable patients, 591 (16%) received E-CPR and 3,165 (84%) received C-CPR only. Survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1–3 or unchanged from admission) were greater for E-CPR [40% (237/591) and 27% (133/496)] versus C-CPR patients [27% (862/3,165) and 18% (512/2,840)]. Odds ratios for survival to hospital discharge and survival with favorable neurologic outcome were greater for E-CPR versus C-CPR. After adjusting for covariates, patients receiving E-CPR had higher odds of survival to discharge [OR 2.80, 95% CI 2.13–3.69, p <0.001] and survival with favorable neurologic outcome [OR 2.64, 95% CI 1.91–3.64, p < 0.001] than patient who received C-CPR. This association persisted when analyzed by propensity-score matched cohorts [OR 1.70, 95% CI 1.33–2.18, p < 0.001 and OR 1.78, 95% CI 1.31–2.41, p < 0.001 respectively]. Conclusions For children with in-hospital CPR ≥ 10 minutes duration, E-CPR was associated with improved survival to hospital discharge and survival with favorable neurologic outcome when compared to C-CPR.

The Residency Review Committee's list of procedures does not necessarily reflect the opinions of pediatric program directors on the most essential skills for trainees. Many residents may not develop competence in several important procedures by the end of residency, most notably vascular access and life-saving skills. A more robust and standardized method is needed for teaching procedural skills and for documenting competence.

Despite many advances in recent years for patients with critical paediatric and congenital cardiac disease, significant variation in outcomes remains across hospitals. Collaborative quality improvement has enhanced the quality and value of health care across specialties, partly by determining the reasons for variation and targeting strategies to reduce it. Developing an infrastructure for collaborative quality improvement in paediatric cardiac critical care holds promise for developing benchmarks of quality, to reduce preventable mortality and morbidity, optimise the long-term health of patients with critical congenital cardiovascular disease, and reduce unnecessary resource utilisation in the cardiac intensive care unit environment. The Pediatric Cardiac Critical Care Consortium (PC4) has been modelled after successful collaborative quality improvement initiatives, and is positioned to provide the data platform necessary to realise these objectives. We describe the development of PC4 including the philosophical, organisational, and infrastructural components that will facilitate collaborative quality improvement in paediatric cardiac critical care.