Use of a Risk Analytic Algorithm to Inform Weaning From Vasoactive Medication in Patients Following Pediatric Cardiac Surgery

Abstract

Advanced clinical decision support tools, such as real-time risk analytic algorithms, show promise in assisting clinicians in making more efficient and precise decisions. These algorithms, which calculate the likelihood of a given underlying physiology or future event, have predominantly been used to identify the risk of impending clinical decompensation. There may be broader clinical applications of these models. Using the inadequate delivery of oxygen index, a U.S. Food and Drug Administration-approved risk analytic algorithm predicting the likelihood of low cardiac output state, the primary objective was to evaluate the association of inadequate delivery of oxygen index with success or failure of weaning vasoactive support in postoperative cardiac surgery patients. DESIGN:Multicenter retrospective cohort study. SETTING: Three pediatric cardiac ICUs at tertiary academic children's hospitals. PATIENTS:Infants and children greater than 2 kg and less than 12 years following cardiac surgery, who required vasoactive infusions for greater than 6 hours in the postoperative period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:Postoperative patients were identified who successfully weaned off initial vasoactive infusions (n = 2,645) versus those who failed vasoactive wean (required reinitiation of vasoactive, required mechanical circulatory support, renal replacement therapy, suffered cardiac arrest, or died) (n = 516). Inadequate delivery of oxygen index for final 6 hours of vasoactive wean was captured. Inadequate delivery of oxygen index was significantly elevated in patients with failed versus successful weans (inadequate delivery of oxygen index 11.6 [sd 19.0] vs 6.4 [sd 12.6]; p < 0.001). Mean 6-hour inadequate delivery of oxygen index greater than 50 had strongest association with failed vasoactive wean (adjusted odds ratio, 4.0; 95% CI, 2.5-6.6). In patients who failed wean, reinitiation of vasoactive support was associated with concomitant fall in inadequate delivery of oxygen index (11.1 [sd 18] vs 8.9 [sd 16]; p = 0.007). CONCLUSIONS:During the de-escalation phase of postoperative cardiac ICU management, elevation of the real-time risk analytic model, inadequate delivery of oxygen index, was associated with failure to wean off vasoactive infusions. Future studies should prospectively evaluate utility of risk analytic models as clinical decision support tools in de-escalation practices in critically ill patients.KEY WORDS: clinical decision support systems; critical illness; low cardiac output; pediatric intensive care unit; physiologic monitoring; risk assessment C ritically ill pediatric patients with congenital and acquired cardiovascular disease have high rates of inhospital cardiac arrest and death (1). Clinical decision support tools aimed at identifying cardiac patients at high risk of clinical deterioration (2-6) have been described in the literature,

A Near Real-Time Risk Analytics Algorithm Predicts Elevated Lactate Levels in Pediatric Cardiac Critical Care Patients

“…In a retrospective multicenter study including infants following CPB operations, Futterman et al ( 16 ) showed that a higher IDO 2 index dose over a monitoring period of 2 hours was associated with an increased risk of cardiac arrest even when censoring data 10–30 minutes before the event. Another retrospective multicenter study showed an association between higher IDO 2 index and failure to wean off vasoactive infusions in pediatric patients following cardiac surgery ( 17 ). The prospective phase of this study is underway.…”

The Inadequate Oxygen Delivery Index and Its Correlation with Venous Saturation in the Pediatric Cardiac Intensive Care Unit

“…Limited data have been published to date regarding the clinical implications of the IDO2 index. Studies to date demonstrated that the IDO2 index can help identify adverse events in children with sepsis, may assist with evaluating extubation readiness in children after cardiac surgery, may aid in early identi cation of children at risk for cardiorespiratory arrest, may aid in weaning vasoactive medications in children after cardiac surgery [31][32][33][34][35]. It should be noted that while these studies have demonstrated utility of the IDO2 index one study failed to nd that the IDO2 index had prognostic utility [36].…”

Novel data visualization and risk analytic algorithm in a low-middle income country

“…18 The IDO2 index can continue to be computed based on previously acquired data even when data is missing at particular points in time. 19 (Figure 2).…”