Vasoactive-Inotropic Score Is Associated With Outcome After Infant Cardiac Surgery

Abstract

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.

Protocolized Treatment Is Associated With Decreased Organ Dysfunction in Pediatric Severe Sepsis*

“…20–22 Data elements available as text fields (e.g., x-ray results, physical exam findings) were extracted by medical record review. PICU severity of illness scores were obtained from the virtual PICU 23 and included the Pediatric Index of Mortality (PIM-2) 24 and the Pediatric Risk of Mortality III (PRISM-III 25 ,) scores. PIM2 is determined based on data from the first hour of PICU care, and PRISM III is determined based on data from the first 24 hours of PICU care.…”

Report of the National Heart, Lung, and Blood Institute Working Group

“…The modules are generally web-based and can be quickly created and deployed to allow “real-time” collection of additional data needed to answer important research questions that may arise. This methodology has been recently successfully used by PC 4 to collect supplemental data to the main registry to study the relationship between Vasoactive-Inotropic Score and outcome after infant cardiac surgery 1,13,32 . A module allowing for capture of additional data related to inotrope use was created, deployed, and linked to the main registry data for each patient.…”

“…A module allowing for capture of additional data related to inotrope use was created, deployed, and linked to the main registry data for each patient. This facilitated efficient data collection with 391 infants prospectively enrolled across 4 centers in just 5 months 32 .…”

Preoperative echocardiographic measures of left ventricular mechanics are associated with postoperative vasoactive support in preterm infants undergoing patent ductus arteriosus ligation

“…The VIS is a validated measure of hemodynamic status based on inotropic need after pediatric cardiac surgery and has been validated as a predictor of prolonged intubation, intensive care unit stay, and total hospitalization in prior studies. 5 The VIS is calculated as follows: $$\mathrm{italicVIS}\mathrm{italicScore}=\mathrm{italicdopamine}\mathrm{italicdose}false(\mu g/kg/\mathrm{italicmin}false)+\mathrm{italicdobutamine}\mathrm{italicdose}false(\mu g/kg/\mathrm{italicmin}false)+false[100\times \mathrm{italicepinephrine}\mathrm{italicdose}false(\mu g/kg/\mathrm{italicmin}false)false]+false[10\times \mathrm{italicmilrinone}\mathrm{italicdose}false(\mu g/kg/\mathrm{italicmin}false)false]+false[10,000\times \mathrm{italicvasopressin}false(\mathrm{italicunits}/kg/\mathrm{italicmin}false)false]+false[100\times \mathrm{italicnorepinephrine}false(\mu g/kg/\mathrm{italicmin}false)false]$$…”

“…1–5 Surgical ligation is an established treatment for a hemodynamically significant PDA when a patient fails or is not a candidate for medical closure. In a subset of patients, PDA ligation leads to impaired left ventricular (LV) systolic performance and a “postligation syndrome” that has been described in the literature as oxygenation failure, hypotension, and the need for increased inotropic support.…”