Browsing by Subject "postoperative care"

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    Multicenter Validation of the Vasoactive-Ventilation-Renal Score as a Predictor of Prolonged Mechanical Ventilation After Neonatal Cardiac Surgery
    (Wolters Kluwer, 2018-11) Cashen, Katherine; Costello, John M.; Grimaldi, Lisa M.; Gowda, Keshava Murty Narayana; Moser, Elizabeth A. S.; Piggott, Kurt D.; Wilhelm, Michael; Mastropietro, Christopher W.; Pediatrics, School of Medicine
    Objectives: We sought to validate the Vasoactive-Ventilation-Renal score, a novel disease severity index, as a predictor of outcome in a multicenter cohort of neonates who underwent cardiac surgery. Design: Retrospective chart review. Setting: Seven tertiary-care referral centers. Patients: Neonates defined as age less than or equal to 30 days at the time of cardiac surgery. Interventions: Ventilation index, Vasoactive-Inotrope Score, serum lactate, and Vasoactive-Ventilation-Renal score were recorded for three postoperative time points: ICU admission, 6 hours, and 12 hours. Peak values, defined as the highest of the three measurements, were also noted. Vasoactive-Ventilation-Renal was calculated as follows: ventilation index + Vasoactive-Inotrope Score + Δ creatinine (change in creatinine from baseline × 10). Primary outcome was prolonged duration of mechanical ventilation, defined as greater than 96 hours. Receiver operative characteristic curves were generated, and abilities of variables to correctly classify prolonged duration of mechanical ventilation were compared using area under the curve values. Multivariable logistic regression modeling was also performed. Measurements and Main Results: We reviewed 275 neonates. Median age at surgery was 7 days (25th–75th percentile, 5–12 d), 86 (31%) had single ventricle anatomy, and 183 (67%) were classified as Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category 4 or 5. Prolonged duration of mechanical ventilation occurred in 89 patients (32%). At each postoperative time point, the area under the curve for prolonged duration of mechanical ventilation was significantly greater for the Vasoactive-Ventilation-Renal score as compared to the ventilation index, Vasoactive-Inotrope Score, and serum lactate, with an area under the curve for peak Vasoactive-Ventilation-Renal score of 0.82 (95% CI, 0.77–0.88). On multivariable analysis, peak Vasoactive-Ventilation-Renal score was independently associated with prolonged duration of mechanical ventilation, odds ratio (per 1 unit increase): 1.08 (95% CI, 1.04–1.12). Conclusions: In this multicenter cohort of neonates who underwent cardiac surgery, the Vasoactive-Ventilation-Renal score was a reliable predictor of postoperative outcome and outperformed more traditional measures of disease complexity and severity.
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    Nicardipine for Hypertension following Aortic Coarctectomy and Superior Cavopulmonary Anastomosis
    (Sage, 2016-01) Mastropietro, Christopher W.; Uribe, Diego Arango; Department of Pediatrics, IU School of Medicine
    Background: Literature on the use of nicardipine, a dihydropyridine calcium channel antagonist, in children recovering from cardiac surgery is sparse and, to our knowledge, nonexistent in children with single ventricle anatomy. We aimed to report our experience with nicardipine in these patient populations. Methods: We performed a retrospective review of children recovering from aortic coarctectomy or superior cavopulmonary anastomoses who received nicardipine for hypertension at our institution between 2007 and 2013. Hemodynamic variables prior to and after nicardipine initiation were compared using paired t tests. Results: Seven children recovering from aortic coarctectomy (median age 8.6 months, range: 1.5 months-7.9 years) and four children recovering from superior cavopulmonary anastomosis (median age: seven months, range: five-nine months) were reviewed. For all patients, at six hours after initiation of nicardipine, mean systolic blood pressure was significantly decreased, 123 ± 19 versus 103 ± 14 mm Hg (P = .001), as were diastolic blood pressure, 68 ± 20 versus 53.5 ± 10 mm Hg (P = .041), and sodium nitroprusside dose, 4.3 ± 2.9 versus 1.3 ± 1.7 mcg/kg/min (P = .002). Further, within 24 hours, serum lactate decreased from 1.45 ± 0.82 to 0.81 ± 0.29 mg/dL (P = .016). Heart rate, blood urea nitrogen, and serum creatinine measurements were statistically unchanged. Conclusions: Nicardipine effectively decreased blood pressure without apparent adverse events in a small cohort of children with postoperative hypertension while recovering from aortic coarctectomy or superior cavopulmonary anastomosis. Further research comparing nicardipine to more conventional titratable antihypertensive agents in these patient populations is warranted.
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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.