Browsing by Author "Walters, Henry L. III"

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    Prevalence and Risk Factors for Upper Airway Obstruction after Pediatric Cardiac Surgery
    (Elsevier, 2015-02) Green, Jack; Walters, Henry L. III; Delius, Ralph E.; Sarnaik, Ajit; Mastropietro, Christopher W.; Department of Pediatrics, Indiana University School of Medicine
    Objective To determine the prevalence of and risk factors for extrathoracic upper-airway obstruction after pediatric cardiac surgery. Study design A retrospective chart review was performed on 213 patients younger than 18 years of age who recovered from cardiac surgery in our multidisciplinary intensive care unit in 2012. Clinically significant upper-airway obstruction was defined as postextubation stridor with at least one of the following: receiving more than 2 corticosteroid doses, receiving helium-oxygen therapy, or reintubation. Multivariate logistic regression analysis was performed to determine independent risk factors for this complication. Results Thirty-five patients (16%) with extrathoracic upper-airway obstruction were identified. On bivariate analysis, patients with upper-airway obstruction had greater surgical complexity, greater vasoactive medication requirements, and longer postoperative durations of endotracheal intubation. They also were more difficult to calm while on mechanical ventilation, as indicated by greater infusion doses of narcotics and greater likelihood to receive dexmedetomidine or vecuronium. On multivariable analysis, adjunctive use of dexmedetomedine or vecuronium (OR 3.4, 95% CI 1.4-8) remained independently associated with upper-airway obstruction. Conclusion Extrathoracic upper-airway obstruction is relatively common after pediatric cardiac surgery, especially in children who are difficult to calm during endotracheal intubation. Postoperative upper-airway obstruction could be an important outcome measure in future studies of sedation practices in this patient population.
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    Risk Factors for Extubation Failure following Neonatal Cardiac Surgery
    (Lippincott Williams & Wilkins, 2015-11) Laudato, Nina; Gupta, Pooja; Walters, Henry L. III; Delius, Ralph E.; Mastropietro, Christopher W.; Department of Pediatrics, IU School of Medicine
    Objective: Extubation failure after neonatal cardiac surgery has been associated with considerable postoperative morbidity, although data identifying risk factors for its occurrence are sparse. We aimed to determine risk factors for extubation failure in our neonatal cardiac surgical population. Design: Retrospective chart review. Setting: Urban tertiary care free-standing children’s hospital. Patients: Neonates (0–30 d) who underwent cardiac surgery at our institution between January 2009 and December 2012 was performed. Interventions: Extubation failure was defined as reintubation within 72 hours after extubation from mechanical ventilation. Multivariate logistic regression analysis was performed to determine independent risk factors for extubation failure. Measurements and Main Results: We included 120 neonates, of whom 21 (17.5%) experienced extubation failure. On univariate analysis, patients who failed extubation were more likely to have genetic abnormalities (24% vs 6%; p = 0.023), hypoplastic left heart (43% vs 17%; p = 0.009), delayed sternal closure (38% vs 12%; p = 0.004), postoperative infection prior to extubation (38% vs 11%; p = 0.002), and longer duration of mechanical ventilation (median, 142 vs 58 hr; p = 0.009]. On multivariate analysis, genetic abnormalities, hypoplastic left heart, and postoperative infection remained independently associated with extubation failure. Furthermore, patients with infection who failed extubation tended to receive fewer days of antibiotics prior to their first extubation attempt when compared with patients with infection who did not fail extubation (4.9 ± 2.6 vs 7.3 ± 3; p = 0.073). Conclusions: Neonates with underlying genetic abnormalities, hypoplastic left heart, or postoperative infection were at increased risk for extubation failure. A more conservative approach in these patients, including longer pre-extubation duration of antibiotic therapy for postoperative infections, may be warranted.
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    Use of a novel vasoactive-ventilation-renal score to predict outcomes after paediatric cardiac surgery
    (Oxford, 2014-12) Miletic, Kyle G.; Spiering, Tyler J.; Delius, Ralph E.; Walters, Henry L. III; Mastropietro, Christopher W.; Department of Pediatrics, Indiana University School of Medicine
    OBJECTIVES Prior studies have established peak postoperative lactate and the vasoactive-inotrope score (VIS) as modest predictors of outcome following paediatric cardiac surgery. We developed a novel vasoactive-ventilation-renal (VVR) score and aimed to determine if this index, which incorporates postoperative respiratory, cardiovascular and renal function, would more consistently predict outcome in this patient population. METHODS We performed an Institutional Review Board-approved retrospective analysis of 222 infants at our institution less than 365 days old who underwent surgery for congenital heart disease at our centre from January 2009 to April 2013. The VVR score was calculated as follows: vasoactive-inotrope score + ventilation index + (change in serum creatinine from baseline × 10). For all patients, peak lactate and admission, peak, and 48 h VIS and VVR were recorded. RESULTS For all outcome measures, areas under the curve for 48-h VVR were greater than its corresponding admission and peak values, VIS alone at all three time points and peak lactate. On multivariate regression, 48-h VVR was strongly associated with prolonged intubation [odds ratio (OR): 39.13, P <0.0001], significantly more so than 48-h VIS (odds ratio: 6.18, P <0.0001) and peak lactate (odds ratio: 2.52, P = 0.017). The 48-h VVR was also more significantly associated with prolonged use of vasoactive infusions, chest tube drainage and ICU and hospital stay when compared with VIS alone and peak lactate. CONCLUSIONS The novel 48-h VVR was a robust predictor of outcome following paediatric cardiac surgery and outperformed the VIS and peak postoperative lactate.