Pediatric cardiology researchers and clinicians gather this week in Scottsdale, Ariz. for Cardiology 2011, the 15th Annual Update on Pediatric and Congenital Cardiovascular Disease, sponsored by The Children's Hospital of Philadelphia. Original research from more than 30 cardiac programs in the U.S. and abroad is being presented throughout the meeting.
The news briefs below highlight 12 research abstracts and posters presented today, which were selected as featured presentations by the conference organizers. The researchers leading these presentations comprise seven nurses and five physicians. All abstracts presented at Cardiology 2011 are published in the January 2011 issue of the World Journal for Pediatric and Congenital Heart Surgery
In Transferring Child Heart Patients from OR to ICU, a Hand Off Protocol Improves Safety by Improving Clinician Communications
Healthcare research has identified breakdowns in "hand off' communication while clinicians transfer patients as a contributor to hospital errors that put patients at risk. One of the highest-risk periods for the safety of critically ill children is the transfer from the cardiovascular operating room (CVOR) to the cardiac intensive care unit (CICU). Nurses, physicians and anesthesia staff at the Children's Hospital (Aurora, Colo.) developed a transfer protocol for this hand-off period. The protocol included equipment checks, routinized steps, the requirement that every staff member be present during report, and even a diagram specifying where each staff member should stand during report. A team led by Christine Peyton, MS, CPNP-AC, CCRN analyzed the results of 20 audits of the CVOR to CICU protocol. There were no adverse events and 95% compliance with the new protocol, with average amount of time for each handoff lasting 7 to 10 minutes.
Christine Peyton MS, CPNP-AC, CCRN, Implementation of a CVOR to CICU Transfer Protocol to Improve Hand Off Communication
Infant Growth Patterns After Newborn HLHS Surgery
Infants born with hypoplastic left heart syndrome (HLHS), a severely underdeveloped left ventricle, must undergo a series of surgeries, typically beginning in the first week of life. In a retrospective cohort analysis, Veena Sivarajan, R.N., and colleagues at the Hospital for Sick Children (SickKids) in Toronto studied feeding and growth patterns in 94 patients who received newborn heart surgery for HLHS. The team compared two types of Stage 1 surgery for HLHS: the Norwood procedure (in 58 patients) and the Hybrid procedure (in 36 patients). Both groups had lower growth rates than those of normal children, with a sharp nadir at 3 to 6 months of age. Of the 94 HLHS patients, 67 survived to the median follow-up time of 2.8 years. Despite attaining full postoperative enteral nutrition more rapidly and a shorter postoperative hospitalization, patients who had undergone the Hybrid procedure had significantly lower growth rates than those who had undergone the Norwood procedure. Veena Sivarajan, RN, et al, Somatic Growth Following Surgical Palliation of Hypoplastic Left Heart Syndrome
Bleeding-Control Drugs Compared for Safety and Efficacy in Newborns Receiving Open-Heart Surgery
Because newborns undergoing open-heart surgery are at risk for perioperative bleeding, more safety and efficacy data are needed regarding bleeding-control drugs. One such drug, aprotinin, has been withdrawn from the adult market because of associated morbidity and mortality, and replaced with lysine analogues. Neither type of medication has been well tested in neonatal heart patients. Nicole S. Wilder, M.D., and colleagues at the University of Michigan Health System performed a single-institution retrospective cohort study of 423 newborns who received heart surgery with cardiopulmonary bypass. Of that population, 271 received aprotinin and 152 received lysine analogues. The aprotinin group had significantly lower transfusion requirements and shorter surgical closure times compared to the lysine analogues group. Furthermore, the lysine analogues group was more likely to require surgical re-exploration and had a higher rate of renal injury. The findings point to a need for further study of aprotinin in a larger population of neonatal heart patients. Nicole S. Wilder, M.D., et al, Efficacy and Safety of Aprotinin in Neonatal Congenital Heart Operations
Family Education in Growth and Nutrition Increases Infants' Transition from Tube Feeding to Oral Feeding between Heart Surgery Stages
Feeding problems are a known complication among infants following surgery for congenital heart disease. Sherry Smith, R.N., led a team at Children's Healthcare of Atlanta in implementing and studying a feeding advancement plan (FAP) used for infants with hypoplastic left heart syndrome. The FAP protocol included a session with a licensed dietitian, parent education on transitioning the baby from continuous tube feeds to oral on-demand feeds, and other instructions. The team analyzed the feeding progression in the period between initial hospital discharge after the Norwood procedure until presentation for the second stage of surgery, the Glenn procedure. There were 24 infants in the study, 10 of whose families received standard feeding instructions, and 13 who underwent the FAP protocol. The FAP significantly increased the rate at which infants transitioned to taking full oral feeds, although there was no difference in the rate of weight gain between both groups. Sherry Smith, RN, et al, Institution of a Feeding Advancement Plan Increases Full Transition from Tube to Oral Feeding in Patients with HLHS
Better Pain-Control Treatments May Be Available to Children during Chest Tube Removal after Heart Surgery
For children who have undergone heart surgery, pain control during chest tube removal has been understudied. This gap in research to guide pediatric practice may result in preventable pain for child patients. Audrey Beckman, BSN, RN, led an experimental, blinded randomized study of pain management at Children's Healthcare of Atlanta. The study team randomized 27 children who had undergone heart surgery into two groups. During chest tube removal, 14 patients received a combination of Toradol and Versed (non-narcotic pain medications), while 13 patients received a morphine-Versed combination. At three time points, nurses evaluated the child's pain using an observational score. In addition, parents and the clinicians who performed the chest tube removal provided assessments of the child's pain during and shortly after the procedure. During the procedure, the difference in pain score was not statistically significant between the two patient groups. However, immediately after the procedure, patients receiving Toradol and Versed experienced significantly less pain than patients receiving morphine and Versed. Audrey Beckman, BSN, RN, et al, Pain Management during Chest Tube Removal in the Pediatric Population
In a Nurse-Led Project, Antiseptic Bath before Child Heart Surgery Reduces Infections at Surgical Site
Surgical site infections (SSIs) are the third most common hospital-acquired infection reported, and HAI's are the eighth-leading cause of death in the U.S. Although there is no national benchmark for pediatric cardiac surgery SSI rates, previous studies have found 2.3% to 3.4% of children undergoing cardiac surgery develop an SSI. The CDC strongly recommends using a preoperative antiseptic bath to prevent SSIs, which are often caused by bacteria residing on the skin. Nurses at the Levine Children's Hospital, in Charlotte, N.C., initiated an intervention to provide an antiseptic bath, using chlorhexidinegluconate within 6 hours before all scheduled heart surgeries for pediatric patients. Melody L. Walblay, RN, CCRN, and colleagues performed a chart review to analyze SSI rates before and after implementing the intervention. They found that SSIs declined sharply, from a baseline rate of 4.17%>Melody L. Walblay, RN, CCRN, et al, A Nursing Intervention to Reduce Pediatric Sternal Surgical Site Infections (SSIs)/i>
Preoperative Corticosteroids May Not Benefit Newborns Receiving Cardiac Surgery
Some researchers have advocated using glucocorticoid drugs to improve postoperative outcomes after newborn heart surgery. A team led by Eric Graham, M.D., at the Medical University of South Carolina, conducted a double-blind randomized controlled trial of 76 neonates who had heart surgery requiring cardiopulmonary bypass. The trial compared the efficacy of preoperative glucocorticoid therapy (methylprednisone 8 hours before surgery and also during surgery, in 39 patients) to the standard single-dose usage (intraoperative methylprednisone only, in 37 patients). Although inflammatory markers dropped before surgery in the two-dose group, this group did not have better clinical outcomes after surgery than the single-dose group. The trial results suggest that physicians should reconsider the routine use of glucocorticoids in neonatal cardiac surgery. The study team recommends conducting a randomized trial to compare intraoperative glucocorticoids to placebo. Eric Graham, M.D., et al, Standardized Preoperative Corticosteroid Treatment in Neonates Undergoing Cardiac Surgery—Results from a Randomized Trial
Closing Heart Duct in Infants with Pulmonary Atresia Increases Early Mortality and Morbidity in Days after Shunt Surgery
Newborns with pulmonary atresia and duct-dependent pulmonary blood flow often must receive surgery to implant a modified Blalock-Taussig (MBT) shunt. The shunt improves pulmonary blood circulation until a subsequent surgery repairs the heart defect. A study team led by Martin Zahorec, M.D., of the National Institute of Cardiovascular Diseases in Slovakia compared the results of closing vs. not closing the patent ductus arteriosus during MBT shunt surgery. In this retrospective observational study, the researchers studied 62 neonates who underwent primary MBT shunt surgery for pulmonary atresia at their institution from 1997 to 2010. The surgeons closed the PDA in 31 patients and left it open in 31 patients. Newborns in the duct closure group had higher mortality 48 hours post-surgery, as well as more resuscitation events and more reinterventions, compared to the newborns whose ducts were left open. Martin Zahorec, M.D., et al, Surgical Ductal Closure Increases Early Mortality and Morbidity after Modified Blalock-Taussig Shunt in Neonates with Pulmonary Atresia
Amount of Vasoactive Drugs Helps Predict Early Outcomes after Infant Heart Surgery
In evaluating early clinical outcomes following neonatal heart surgery, clinicians have used two markers: low cardiac output syndrome (LCOS) and maximum vasoactive inotropic score (VIS). The current study aimed to compare these markers to each other and to early clinical outcomes. Ryan Butts, M.D., and colleagues at the Medical University of South Carolina prospectively studied 76 newborns receiving heart surgery that required cardiopulmonary bypass. During the first 36 hours after surgery, the researchers used records of all vasoactive medications to calculate the VIS—an indicator of the level of cardiovascular support. Higher VIS correlated with a longer duration of mechanical ventilation, longer ICU stay and higher hospital charges. Correlations between these outcomes and LCOS scores were not significant, suggesting that VIS is a better surrogate marker than LCOS for important early postsurgical outcomes.
Ryan Butts, M.D., et al, Maximum Vasoactive Inotropic Score Is Superior to Low Cardiac Output Syndrome as a Predictor of Early Outcomes Following Neonatal Cardiac Operations
Respiratory Therapists' Protocol Improves Care and Outcomes for Children in Pediatric Cardiac ICUs after Surgery
Using respiratory therapist-driven protocols for respiratory care in the ICU has been shown to be safe and to reduce both ventilator time and ICU length of stay. However, studies have not been reported on the safety and efficacy of such protocols in pediatric heart surgery patients. Researchers at St. Joseph's Hospital and Medical Center in Phoenix, led by Courtney Howell, CPNP, evaluated a newly instituted, respiratory-therapist-driven respiratory care protocol at their hospital. In a retrospective chart review, they analyzed seven outcomes in 267 children after cardiac surgery. There were 145 patients who received care in the six months before the protocols were instituted, compared to 122 patients in the post-protocol group. In the post-protocol group, the study team found a dramatic reduction in postoperative length of intubation (10 hours vs. 22 hours in the pre-protocol group) and a drastic reduction in the number of patients receiving mechanical ventilation longer than 7 days (7% vs. 1%). Other outcomes (mortality, postoperative pneumonia, pneumothorax, and need for reintubation) all trended downward, but were not statistically different between both groups.
Courtney Howell, CPNP, et al, Safety and Efficacy of Respiratory Therapist-Driven Respiratory Care Protocols in a Pediatric Cardiothoracic Intensive Care Unit
QI Program Cuts Infections from Implanting Pacemakers and Defibrillators in Children
Cardiac implantable device-related infection (CDI) is a significant complication of treating patients for cardiac arrhythmias. However, clinical practices and guidelines to minimize CDI have not yet been established. Jamie Ganley, R.N., and colleagues at The Children's Hospital of Philadelphia evaluated the efficacy of institutionally developed practice guidelines in reducing CDI in a cohort of pediatric and congenital heart disease patients who received pacemakers or implantable cardioverter defibrillators at their hospital. The guidelines specified the application of indicated antiseptics and antibiotics at particular times before device implantation. In this single-institution study of 309 patients, adherence to the guidelines significantly reduced the incidence of cardiac device infections, from 15% in the year before the guidelines were implemented, to 4.7% in the subsequent year. All the infections during the study period (19 in 309 patients) were in pacemaker implantations, with no infections from implantable cardioverter defibrillators.
Jamie Ganley, RN, et al, Establishing Institutional Practice Guidelines to Reduce Cardiac Implantable Device Infections: An Endeavor in Quality Improvement
Hypertension in Pulmonary Arteries Is Worse in Adults than in Children
REVEAL is the Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management, a multicenter, observational U.S. study. Robyn Barst, M.D., of Columbia University College of Physicians and Surgeons, led a team that compared the characteristics of children and adults diagnosed with idiopathic pulmonary arterial hypertension (IPAH). The researchers analyzed records from 1,386 patients with IPAH, of which 1,287 had adult-onset IPAH and 99 had childhood-onset IPAH. The patients with adult-onset IPAH had worse hemodynamics and were in a worse functional class at diagnosis compared to patients with childhood-onset IPAH, despite the fact that the childhood-onset group had more presyncope and syncope. Adult-onset patients start treatment significantly earlier after diagnosis than the childhood-onset patients. For both groups, only a minority of patients receive acute vasoreactivity testing (AVT), despite a considerable number of patients receiving calcium-channel blocker therapy without AVT.
Robyn Barst, M.D., et al, REVEAL Registry: Comparison of Patients with Childhood-Onset and Adult-Onset Idiopathic Pulmonary Arterial Hypertension
The Children's Hospital of Philadelphia