Proceedings of the 2005 Pediatric Cardiac Intensive Care Symposium

The 2005 Pediatric Cardiac Intensive Care Symposium December 711, 2005 South Beach, Miami, FL Editor: Anthony C. Chang, MD, MBA

1 TRACHEAL EXTUBATION AFTER CARDIOTHORACIC SURGERY IN NEONATES, CHILDREN, AND YOUNG ADULTS: ONE YEAR OF INSTITUTIONAL EXPERIENCE Manrique A, Feingold B, Di Filippo S, Orr D, Munoz R. Pittsburgh, PA
Objective: Identify criteria to predict successful and early extubation in the pediatric cardiac intensive unit (CICU). Methods: Retrospective charts review of 212 patients from January 2003 to January 2004, deaths were excluded. Demographic data, previous lung disease, other congenital abnormalities, previous pulmonary hypertension, anesthetic technique, cardiopulmonary bypass time, cross-clamp time, circulatory arrest time, type of repair by RASCH-risk categories, preextubation ventilator settings, mechanical ventilation time, blood arterial gases, postoperative ventricular function, inotropic support, sedation, re-intervention, CICU stay and hospitalization days were studied . Early extubation was dened as mechanical ventilation 24 hrs and success as no reintubation at any time during the CICU course. Results: Mean 3.5 5.4 yrs old 57% of patients were 1 yr old and 10% were premature infants. 58 (27%) were extubated in the theater, and 122 (57.5%) of patients were extubated early (mean, 7.7 hrs; 95% CI, 7.716). Only 7 patients failed: 3 (5.1%) in the theatre by upper airway obstruction and 4 (1.9%) in the CICU for acute respiratory failure from atelectasis (n 2), ventricular dysfunction (n 1), and arrhythmia (n 1). There were no extubation failures in patients who were extubated after 24 hrs postsurgery. (Table 1). Forward logistic regression model showed that prematurity (p .001), and return to the operating room before extubation (p .001) were predictors of extubation failure. Failure was associated with longer CICU and hospital stay (.05). Conclusions: A rst trial extubation was successful in 99.98% of patients excluding prematurity and surgical reintervention. Surgical complexity was associated with length of intubation but did not predict failure. Unlike previous reports, our study showed a high rate of successful extubation in all patients after cardiothoracic surgery.

2 EVALUATION OF THE COAGULATION SYSTEM IN CHILDREN WITH TWO-VENTRICLE CONGENITAL HEART DISEASE Kirsten C. Odegard, MD, Stephan Hornykewycz, MD, David Zurakowski, PhD, James A. DiNardo, MD, Robert A. Castro, MT, Peter C. Laussen, MBBS. Department of Anesthesia, Childrens Hospital Boston, Harvard Medical School, Boston MA
Introduction: Multiple coagulation factor abnormalities involving both pro-and anticoagulant proteins have been described in children with single ventricle physiology (1, 2). Coagulation factor levels in patients with two-ventricle congenital heart disease (CHD) is unknown. In this study we compared factor levels in infants and children with twoventricle CHD before cardiac surgery with age-matched controls. Materials and Methods: With informed consent, coagulation factors were assayed in 120 infants and children with two ventricle CHD; divided into four groups: group I (0 3 months; mean age, 28 30 days), group II (312 months; mean age, 6 3 months), group III (12 48 months; mean age, 30 10), and group IV (48 months; mean age, 7.7 3 yrs). Healthy children without CHD were assayed as controls (group II, 7.8 2.2 months; group III, 26 12 months; and group IV, age 8.3 2.9 yrs), published control values were used to compare with group I (3) due to difculties obtaining consents from healthy neonates. Clotting assays included: factors II, V, VII, VIII, IX, X, protein C and S, plasminogen and antithrombin III. Data represent mean SD; 2-tailed Bonferroni adjusted p .005 to account for multiple comparisons. Results: Signicant differences were detected between group I vs. controls for all variables except factor V, X, plasminogen, and protein S; group II for all variables except factors V, VIII and protein S; group III for all variables except factor VIII, IX, ATIII and protein S, and group IV there were no signicant differences (Table). Conclusion: Coagulation factor concentrations and activities mature at varying rates after birth, with some not approaching adult values until late childhood (3). This study found that, compared with healthy infants of similar age, there was a high incidence of both pro- and anticoagulant factor abnormalities in patients 48 months of age with two ventricular CHD, approaching normal levels in children 48 months. These coagulation factor abnormalities are similar to those we have described in patients with single ventricle physiology 48 months of age (4). Whether these abnormalities are part of a genetic predisposition, result from hemodynamic or pathophysiologic abnormalities in patients with CHD in general such as altered cardiac out put, congestive heart failure or failure to thrive is not known. REFERENCES
1. Odegard et al. Ann Thorac Surg 2002; 73:1770 1777 2. Odegard et al. J Thorac Cardiovasc Surg 2002; 123:459 465 3. Andrew et al. Blood 1987; 70:165172 4. A1325 (ASA 2005)

Table. Category Theater Early Delayed Extubation Time Hours Mean SEM 2.6 1.5 11.4 3 20 4.3 75 28 68 4 21.4 3 20.5 3 Total

1 2 3 4 6 Heart Transplant and Thoracic Total

23 10 (FAILED 2) 25 (FAILED 1) 0 0 0 58

7 48 (FAILED 2) 55 (FAILED 2) 7 0 5 122

1 3 11 5 7 5 32

31 61 91 12 7 10 212

Table. Ages, Months 3 Controls Variable Factor II Factor V Factor VII Factor VIII Factor IX Factor X ATIII Plasminogen Protein C Protein S 66 68 17 98 18 90 24 91 33 51 15 59 14 78 15 NA 43 11 63 15 Patients 30 52 11a 84 21 55 17a 58 22a 34 10a 47 14 56 16a 45 11 26 9a 55 18 Controls 30 90 12 117 18 88 20 77 20 66 15 95 14 106 13 88 15 81 17 89 20 312 Patients 30 72 14a 97 28 69 19a 62 20 48 16a 66 16a 85 15a 69 13a 47 11a 75 15 1248 Controls 38 93 10 109 16 88 18 85 22 69 11 93 11 105 16 100 20 98 20 86 15 Patients 30 83 10a 93 17a 71 14a 79 19 63 14 79 10a 96 10 89 10a 72 12a 85 18 48 Controls 34 95 15 103 24 92 27 96 32 80 21 90 17 108 11 98 14 95 22 87 16 Patients 30 86 10 92 13 77 20 74 21 67 14 80 12 99 9 90 10 83 14 81 19

ap .005. Data are mean SD. Groups were compared by the Students t-test (2-tailed) since all variables followed a normal distribution.

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3 PREOPERATIVE MANAGEMENT OF STAGE I: SINGLE INSTITUTIONAL EXPERIENCE 20012005 Manrique A, Di Filippo S, Motoa MV, Morell V, Mun oz R. Pittsburg, PA
Objective: Describe 4 yrs experience with preoperative management of stage I. Identify factors and current strategies of therapy associated with optimal preoperative status. Methods: Retrospective chart review from 2001 to 2005. Preoperative data including, prenatal diagnosis, gestational age, age at admission, age at surgery, mechanical ventilation, hypoxemic therapy with nitrogen, echocardiographic data, evidence of multiorgan failure, need of septostomy, inotropic support, serum creatinine, arterial pH and BE, whole blood lactate level, hemodynamic data and mortality were analyzed. Results: Thirty patients underwent stage I repair (mean age at admission, 1.3 1.7 days; mean age at surgery, 7.2 3.7 days). There was an increase in prenatal diagnosis (p .04), use of hypoxemic therapy (.01) and use of milrinone (p .01) over the yrs. In addition, there was a trend to decrease the number of mechanically ventilated patients on admission to the Cardiac Intensive care Unit (CICU) (p .1).Early admissions to the CICU (5 days) was associated with lower lactate levels compared with late admissions (p .01). Patients who had prenatal diagnosis had lower lactate levels (p .05) and lower dopamine requirements (p .04). Likewise, prenatal diagnosis was associated with decreased need of mechanical ventilation (p .01). Sixty six percent of patients who received hypoxemic therapy did not required preoperative ventilatory support and had higher base excess before surgery. The use of milrinone was associated with lower lactate levels (2.7 vs. 6.2 mmol/L), higher arterial pH (p .02), higher PaO2 (p .03) and higher BE (p .04). All patients who died did not receive preoperative milrinone. Institutional 30 days survival rate was 76.7% Conclusion: Prenatal diagnosis and the preoperative use of after load reduction have increased over the last 4 yrs. These changes are associated with signicant improvement in cardiac output before surgical intervention. The use of milrinone may allow us to increase oxygen delivery without the deleterious consequences of overcirculation.

5 A NOVEL CLINICAL OUTCOME SCORE: PREDICTING THE SEQUELAE OF INFANT HEART SURGERY Vamsi Yarlagadda, David Wypij, Peter Laussen, Stephen Roth, Andrew Mackie, Jane Newburger. Childrens Hospital Boston, Boston, MA
Background: As new strategies in infant heart surgery are developed, randomized trials seek to assess whether they result in improved hemodynamic and cognitive outcomes compared with standard methods. Primary outcomes such as hospital length of stay (LOS) or neurodevelopmental outcome require large sample sizes or lengthy patient follow-up. Validated surrogate outcome measures are needed to assess new strategies efciently. Methods: We examined the predictive validity of a composite clinical outcome score (CCOS) (see Table). We used multivariable proportional hazards and linear regression to investigate whether the CCOS predicted LOS (ICU and hospital) and Psychomotor Developmental Index (PDI score) at age 1 yr, respectively, adjusting for diagnosis and specic trial. Analyses were performed using prospectively gathered data on 711 infants enrolled in randomized trials of perioperative management strategies at our institution between 1988 and 2004. Results: Diagnoses were grouped as follows: D-TGA group (D-TGA with IVS or VSD, n 396), conotruncal group (TOF, TOF/PA, and truncus arteriosus, n 165), VSD group (VSD or CCAVC, n 97), and high-risk diagnoses (HLHS, other single ventricle requiring Norwood procedure, interrupted aortic arch and VSD, n 53). Of the 711 patients, 546 were invited to return for follow-up, and 504 (92%) returned for neurodevelopmental evaluation at age 1 yr. Seven patients (1%) died between surgery and follow-up. Adjusting for diagnosis and trial, the hazard ratio (HR) per point increase in the CCOS was 0.38 (p .0001; 95% CI, 0.33 0.42). Thus, in patients with the same diagnosis enrolled in the same trial, each increase of one point in the CCOS was associated with a 62% lower chance of being discharged from the ICU at any point in time. Similarly, for hospital LOS, the HR per point increase in the CCOS was 0.47 (p .0001; 95% CI, 0.42 0.52). Adjusting for diagnosis and trial, the CCOS was signicantly predictive of 1-yr PDI (p .006), with an estimated coefcient of -2.5 (95% CI, -2.6 to -2.3). Thus, in patients with the same diagnosis enrolled in the same trial, each increase of one point in the CCOS was associated with a fall in 1-yr PDI score of 2.5 points. Inclusion of other medical and sociodemographic variables in the models did not appreciably change the study inferences. Conclusions: The CCOS is a robust surrogate for outcomes that are broadly recognized to be of clinical importance and may be useful as a primary outcome variable in future surgical trials in neonates and infants. The predictive validity of this score should be tested in multicenter studies.
Table. CCOS
Score Clinical Variable Time until rst negative uid balance (days) Time until sternal closure (days) Time until rst extubation (days) Death or use of ECMO assigned score of 7 0 3 2 4 1 45 34 58 2 6 5 9

4 WORSENING RENAL FUNCTION IN CHILDREN HOSPITALIZED FOR ACUTE DECOMPENSATED HEART FAILURE: EVIDENCE FOR A PEDIATRIC CARDIORENAL SYNDROME Jack F. Price,1 Antonio R. Mott,1 Anthony C. Chang,1 Heather A. Dickerson,1 William J. Dreyer,1 Susan W. Deneld,1 Jeffrey A. Towbin,1 Stuart L. Goldstein.2 1Cardiology Section, 2Renal Section, Department of Pediatrics, Baylor College of Medicine, Texas Childrens Hospital, Houston, TX
Background: Worsening renal function occurs commonly in adults hospitalized for acute decompensated heart failure (ADHF), but data are lacking in children. The purpose of this study was to determine the incidence and severity of renal insufciency in children with ADHF and whether worsening renal function predicts adverse cardiovascular outcome. Methods: We performed a prospective observational cohort study of all patients (pts) admitted to our institution with ADHF from 10/2003 to 10/2005. We dened ADHF as new onset or acute exacerbation of HF signs/symptoms requiring hospitalization and treatment with intravenous diuretics with or without inotropic medications. Worsening renal function was dened as an increase in serum Cr of 0.3 mg/dL during hospitalization. Pts 21 yrs of age and pts with a known history of renal failure were excluded. Results: Sixty-three pts (35 male, 28 female) comprised 73 pt hospitalizations. Serum creatinine data were available for 72 hospitalizations. Median age at admission was 10 yrs (range, 0.120.3 yrs). Median serum Cr at admission was 0.6 mg/dL (range, 0.23.5 mg/dL) and median GFR was 103 mL/min/1.73m2 (range, 22 431 mL/min/1.73m2). The initial serum creatinine (Cr) was 1.2 mg/dL in 12/72 (17%) pt hospitalizations. Serum Cr rose during 47/72 (65%) pt hospitalizations (median increase, 0.1 mg/dL; range, 0.12.7 mg/dL) and increased by 0.3 mg/dL in 27/72 (38%) pt hospitalizations. Pts whose serum Cr increased 0.3 mg/dL while hospitalized were at increased risk of the combined endpoint of in-hospital death or need for mechanical circulatory assistance (13/27 vs. 4/45; RR 5.4; p .001). Worsening renal function was also associated with a greater hospital length of stay (28 12 days vs. 15 12 days; p .004). Pts treated with nesiritide were at increased risk of worsening renal function (22/46 vs. 5/25; RR 2.86; p .02). Four pts required continuous renal replacement therapy and two pts required hemodialysis. One pt underwent renal transplant at the time of heart transplant. Conclusions: Worsening renal function occurs commonly in children hospitalized with ADHF and may predict in-hospital mortality or the need for mechanical circulatory assistance. Use of nesiritide may be associated with worsening renal function in children with ADHF.

6 EFFECTIVENESS OF DEXMEDETOMIDINE ADMINISTRATION IN FONTAN-TYPE OPERATION N. Tokuhira, K. Atagi, A. Ujiro H. Shimaoka. Intensive Care Unit of Osaka City General Hospital, Osaka, Japan
Purpose: In Fontan-type operations, which have been widely used, delicate postoperative management as well as operative techniques is required for getting good outcomes. Especially, since it is very important to control pulmonary vascular resistance (PVR) as postoperative management, pulmonary vasodilators or nitric oxide (NO) are used and early extubation is required to shorten the period of positive pressure ventilation. Although sedation is useful for decreasing PVR, it needs to be careful not to suppress spontaneous respiration too much. However, as far as using conventional medicines for children, it is difcult to get ideal sedation level without excessive respiratory suppression. Recently, a new 2-adrenoceptor-selective agonist, dexmedetomidine (DEX), has been launched and applied as a good sedative with less respiratory suppression. We used DEX for post-Fontan procedure in ICU during mechanical ventilation and after extubation, and got good control. Method of Investigation: From Aug 2004 to Aug 2005, ve pediatric patients underwent Fontan type operation. Setting: Intensive care unit of Osaka City General Hospital (OCGH). DEX administration was started after admission to ICU, and continued after extubation. DEX was continuously infused intravenously without initial loading dose. Patients could be treated with additional medications, if the sedation level was still insufcient. To achieve the optimal sedation level, the infusion date of DEX was adjustment as needed. We used the pediatric sedation score of OCGH which have six-point scale (Table 1).The following data were collected: administration rate of DEX, usage of other medicines for sedation and/or analgesia, sedation score, blood pressure, heart rate, and respiratory rate. Result: Five children underwent Fontan operation and were administrated with DEX in ICU (a 20-month-old girl double outlet right ventricle (DORV), a 14-month-old boy tricuspid atresia, a 5-yr-old boy pulmonary atresia, a 18-month-old-boy DORV, a 2-yr-old-girl muscular ventricular septal defect). The length of mechanical ventilation in ICU was 8.4 0.65 (range, 7590 hrs). The initial dose of DEX was 0.23 0.66 (range, 0.33 0.2 g/kg/hr), maximum dose during intubation was 0.36 0.17 (range, 0.60 0.2 g/kg/hr), maximum dose after extubation was 0.66 0.36 (range, 0.30 1.00 g/kg/hr). These patients did not need extra medicine for sedation or analgesia and showed good sedation, had stability of hemodynamic state, no respiratory depression while 24 hrs ICU stay (during and after mechanical ventilation). They could be smoothly weaned from mechanical ventilation and extubated without agitation. There was no clinically signicant side effect (bradycardia, hypotension) Conclusion: Dexmedetomidine is useful for Fontan procedure postoperative management, because it brings effective sedation level without respiratory suppression, and then this provides suitable degree of pulmonary vascular resistance.

Table. Sedation score of OCGH

Score 2 1 0 1 2 3 Agitated and restless Awake and uncomfortable Awake and calm Wake up easily by stimuli Wake up by strong stimuli No response

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7 HYPERGLYCEMIA IN PEDIATRIC PATIENTS ON EXTRA CORPOREAL MEMBRANE OXYGENATION

Ferns Sunita Juliana, Nichani Sanjiv, Suresh S, Lall Rajesh. Gleneld Hospital, University Hospital of Leicester, UK.
Objective: To investigate the prevalence and prognostic signicance of increased blood glucose concentration and its correlation to mortality in patients on extra corporeal membrane oxygenation (ECMO). Design: Retrospective case note audit. Setting: ECMO admissions to a pediatric intensive care unit. Patients: 102 patients aged 1 day to 18 yrs. Materials and Methods: Blood glucose measurements were retrieved from intensive care unit charts. Hyperglycemia was dened as a venous glucose measurement 10 mmmol/L (180 mg/dL) within 110 days of admission. Glucose levels elevated in the terminal stages 6 hrs before the death of the infant were excluded from the study. Patients demographic data collected included data relating to the type of nutrition, the glucose intake, markers of sepsis, multiorgan dysfunction (liver, renal, or neurologic impairment), and acidosis. Know diabetics were excluded from the study. Use of pressor support, steroids and insulin was noted. The clinical outcome was recorded as death or survival to discharge from the ICU. Patients were characterized into two groups depending on the presence or absence of hyperglycemia. The association of hyperglycemia to outcome, multiorgan dysfunction, acidosis etc was computed. Statistical tests used were the chi square test and a logistic regression analysis. All tests were conducted at a signicance level of .05. Results: The overall ITU mortality rate in the study period was 17.5% (18). The median length of stay was 7 days (range, 1 62). The mortality rate in the hyperglycemias was 27.5 % and in the normoglycemic was 11.29%. There was no signicant difference between the two groups regarding the diagnosis responsible for admission and the prevalence of sepsis was not signicantly different between the two groups. Hyperglycemia was present in 40 (38.8%) patients whereas 62 (60.2%) patients were normoglycemic on admission. There was a signicant association between hyperglycemia and mortality (p .019; R -.18). Glucose levels also affected the length of stay. Conclusion: The most prominent nding of the study is the high prevalence of hyperglycemia in patients on ECMO and the increase in the morbidity and mortality in patients with hyperglycemia as compared with the normoglycemics. We hope that this provides a framework for further investigations into the benecial effects of closely controlled blood sugar levels in critically ill infants and children.

9 MESENTERIC REGIONAL OXIMETRY BY NEAR-INFRARED SPECTROSCOPY IN NEONATES UNDERGOING CARDIAC SURGERY Brian K. Eble, Gary E. Stapleton, Dean B. Andropoulos, Debora L. East, Antonio R. Mott, Heather A. Dickerson, Jack F. Price, E. Dean McKenzie, Charles D. Fraser, Anthony C. Chang
Purpose: Neonates who require cardiac surgery for congenital heart disease (CHD) are at increased risk for morbidity and mortality related to inadequate systemic oxygen delivery. The gastrointestinal tract may be at greater risk for ischemia in these patients secondary to cyanosis, ductal-dependent circulation, and low cardiac output. The purpose of this study was to evaluate the use of near-infrared spectroscopy (NIRS) as a noninvasive monitor of cerebral and somatic oxygenation in neonates during this perioperative period. Methods: Neonates 1 month of age with CHD were enrolled before cardiac surgery. A NIRS sensor (Somanetics 5100B, Troy, MI) was placed on the right forehead, and on the midline lower abdomen. Cerebral (crSO2) and mesenteric (mrSO2) regional oxygen saturations were then recorded continuously for 24 hrs preoperatively, intraoperatively, and 48 hrs postoperatively. Results: Twenty-nine patients were enrolled. Ten had hypoplastic left heart syndrome and underwent a Norwood operation (1V). Nineteen had a biventricular repair (BiV), including 12 with d-transposition of the great arteries. The preoperative and postoperative regional oxygen saturations for each group are listed in Table 1. There were no early deaths. Three 1V patients had poor outcomes (2 late deaths, 1 ECMO), and had signicantly lower postoperative mrSO2 compared with the rest of group 1V (39.1 vs. 54.7; p .01). One BiV patient developed acute renal failure postoperatively, and had signicantly lower mrSO2 compared with the rest of group BiV (41.1 vs. 65; p .01). Conclusions: A signicant decrease in postoperative mrSO2 is associated with increased risk of morbidity and mortality in neonates in the postoperative period. The regional saturation threshold for signicant gastrointestinal injury is not known, although the frequency of low values in these patients suggests that the threat of ischemia is common. Identication of patients with poor systemic O2 delivery in the perioperative period using NIRS may allow early intervention, and improved long-term outcomes.

Table. Demographic and clinical data of study patients

Normoglycemics No. (%) Age Sex Male Female Days admitted Days on ECMO Catecholamine use Sepsis Organ dysfunction Cardiac Liver Renal CNS Acidosis TPN Use of steroids Deaths 1 day18 yrs (1 day) 36 26 9 6.5 44 17 38 2 4 9 24 20 3 6 Hyperglycemias No. (%) 1 day17 yrs (3 days) 17 23 10.2 5.5 34 16 31 6 16 7 29 21 10 11 Signicance (p) .2 .03 .12 .45 .26 .1 .18 .09 .03 .00 .68 .001 .04 .00 .01

Table. Mean regional oxygen saturations n Preoperative mrSO2 48.0 42.5 Postoperative mrSO2 52.6 63.7 p Value Preoperative crSO2 60.7 58.5 Postoperative crSO2 49.9 67.9 p Value

Group 1V Group BiV

10 19

0.34 0.001

.002 .001

8 KETAMINE DOES NOT INCREASE PULMONARY VASCULAR RESISTANCE IN CHILDREN WITH PULMONARY HYPERTENSION Chandra Ramamoorthy, Bridget Philip, Stanton Perry, Jeffrey Feinstein, Gail Boltz, Glyn Williams. Stanford University Medical Center, Stanford, CA
Statement of Purpose: Presence of pulmonary hypertension signicantly increases the perioperative risk of morbidity and mortality. Ketamine is an useful anesthetic agent in children as it provides analgesia, maintains systemic arterial pressure and does not cause respiratory depression. The use of ketamine in children with pulmonary hypertension is controversial. This prospective study of intravenous ketamine anesthesia in children with pulmonary hypertension was set up to evaluate its effects on pulmonary vascular resistance during spontaneous ventilation .

10 NORMOGLYCEMIA IN PEDIATRIC CARDIAC INTENSIVE CARE: DOES IT MATTER?

Turner L, Cassidy J. Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
Hyperglycemia as a result of insulin resistance is common in critically ill children (1). In adults this has been shown to be associated with an increase in mortality and morbidity (2) and there is increasing evidence that this may also be true for children (1). In view of this our unit policy changed to target normoglycemia in all patients, using a standard insulin sliding scale, to achieve blood sugar levels of 47 mmol/L. Methods: A prospective audit was carried out over a 4-month period. We aimed to establish: 1) the incidence of hyperglycemia in our patient population; 2) the amount of insulin required for normoglycemia; 3) compliance; and 4) potential complications associated with the regime. Results: Over the 4-month period, 87 children were admitted to the PICU: 79% following cardiac surgery. 3 children died: 1 as a result of neonatal multiorgan failure in association with sepsis and protein C deciency, 1 as a result of devastating neurologic injury following a modied Norwood 1 operation for hypoplastic left heart syndrome and 1 who was referred for cardiac transplant following a failed Fontan and who died before a donor heart was offered. Overall, 58 (67%) children had blood sugars of 7 mmol/L. Of these 25 children were treated with insulin. The mean amount of insulin required to achieve normoglycemia was 0.13 u/kg/hr (range, 0.010.77 u/kg/hr). All 25 children were on inotropes: 92% on adrenaline and 44% had evidence of other organ failure also. 56% required 0.1 u/kg/hr and 28% 0.2 u/kg/hr of insulin to achieve normoglycemia. Insulin requirements rose with increasing organ failure (Fig. 1). In the 33 children with documented blood sugars 7, who did not receive insulin 82% of these had a blood sugar 12 and 75% were hyperglycemic on day 1 PICU only. 7 children had documented asymptomatic hyperglycemia (range, 1.21.9 mmol/L). All were infants and 3 were neonates. In all, the hypoglycemia was explainable by the protocol not being followed: ve were nil by mouth and the insulin infusion was not stopped, one did not have a blood sugar checked for 3 hrs, and one child had a nonstandard scale used. No child had symptomatic hypoglycemia. Conclusions: Hyperglycemia is common in our patient population. There is a trend toward increasing organ failure with escalating insulin requirements and this is a proxy marker of illness severity. There is reluctance to treat modest degrees of hyperglycemia and a signicant incidence of asymptomatic hypoglycemia when blood sugars are not closely monitored. A multicenter randomized controlled trial of insulin therapy in critically ill children could resolve this debate 1. Srinivasan, et al: Association of timing, duration and intensity of hyperglycemia with intensive care unit mortality in critically ill children. Pediatr Crit Care Med 2004; 5:329 336 2. Van Den Berghe, et al: Intensive insulin therapy in the critically ill patient. N Engl J Med 2001; 345:1359 1367

Results: n 7; age (yrs): 7.6 (range, 3 mos14 yrs); weight (kg): 29.2 (range, 6.5 67). None of the measured parameters changed in the 15 mins following ketamine load. There were no adverse effects associated with the use of ketamine thus far. Conclusions: In this study of children with pulmonary hypertension receiving 0.51 MAC of sevourane anesthesia, a 2 mg/kg bolus of ketamine followed by a 10 g/kg/min infusion did not increase the pulmonary vascular resistance. There were no other hemodynamic alterations. This group of children often present for interventions requiring anesthesia and have an increased risk of anesthetic complications. Aggravations in PVR related to airway instrumentation has been reported in patients with pulmonary hypertension. By using ketamine spontaneous ventilation with normocarbia was maintained in this study. Furthermore ketamine could be valuable for preserving coronary perfusion to the at-risk right ventricle because it does not increase pulmonary vascular resistance and maintains systemic MAP without causing tachycardia.

Method of Investigation: Patients between 3 months and 18 yrs of age, undergoing cardiac catheterization for evaluation of pulmonary hypertension were studied after institutional and parental consent. Following premedication with oral midazolam (0.5 0.75 mg/kg) and mask induction with oxygen and sevourane, venous and arterial access was obtained. Baseline mean systemic and pulmonary arterial pressure data and arterial blood gases were obtained on 0.51 MAC of sevourane in air. Patients then received an IV ketamine bolus (2 mg/kg) over 5 mins followed by an IV ketamine infusion at 10 g/kg/min. Sevourane/air was continued at 0.51.0 MAC and all patients were breathing spontaneously. Five, 10, 15 mins after end of ketamine bolus hemodynamic and blood gas data were obtained. Mean data are presented and paired t-test performed; signicance set at p .05.

REFERENCES

Table. Parameter MAP, mm Hg Mean PAP, mm Hg PVR, Wood units HR, bpm SpO2, % PaCO2, mm Hg Baseline 62 52 11 104 94 49 5 Mins 66 50 11 103 93 49 10 Mins 66 53 11.5 93 93 49 15 Mins 67 53 11.5 100 94 48

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11 OUTCOME FOLLOWING MECHANICAL SUPPORT AS A BRIDGE TO PEDIATRIC CARDIAC TRANSPLANTATION Cassidy J, Wrightson N, Thiru Y, Smith JH, Hamilton JRL, Dilworth K, Haynes SR, Kirk R, Hasan A
Objective: The policy in our institution is to offer mechanical support to a patient with dilated cardiomyopathy with 2 organ failure who is deteriorating despite inotropic support. We do not offer mechanical support to infants 1 yr of age. We compared mortality between children with dilated cardiomyopathy who required mechanical support with either extracorporeal membrane oxygenation or a paracorporeal ventricular assist device as a bridge to transplantation vs. those requiring medical support only. Methods: Retrospective review over a 58-month period (January 2000 October 2005) in one of the two UK pediatric cardiac transplant centers. Results: 57 children with dilated cardiomyopathy were assessed for cardiac transplantation with a median age of 33 months (interquartile ranges, 13 months9.5 yrs). Of these, six were subsequently removed from the listve because of clinical improvement and one because of a progressive neurologic condition. 33 children were transplanted, two are actively listed and 7 died awaiting transplant. Nine children remain under regular follow up but are not currently felt to warrant active listing. Overall, ten (20%) of children listed died: seven (14%) waiting for a heart and three (6%) following transplant. 13 (25%) children received mechanical support as a bridge to transplantation. Of these 13, 9 (75%) survived to transplantation. Five children were supported with a paracorporeal biventricular assist device, with four surviving to transplant and 8 with ECMO, of whom ve survived to transplant. 1 of these deaths was as a result of sepsis, the others, the consequence of thromboembolic neurologic injury. Two children (one ECMO and one VAD) died posttransplant one of acute rejection and one of devastating neurologic injury. In the 30 children managed medically, 24 have been successfully transplanted, four have died waiting and two remain listed. In those children who died without mechanical support being offered, one was an infant, one died suddenly at home, one developed total ischemic colitis and one died in her local pediatric intensive care unit before transfer could be arranged. Only 1 child supported medically, died posttransplant. Survival overall in the medical group is therefore 87%. Survival overall in the mechanical support group is 54% Conclusion: While mortality is signicantly higher in those children requiring mechanical support as a bridge to transplantation: 25% vs. 13%, it is still possible to achieve good survival in this high risk group. The majority of the attrition (3/5 deaths) is the result of thromboembolic complications.

13 INFANT CPB: EFFECT OF REFRIGERATED WHOLE BLOOD PRIME ON PLATELET COUNT AND FIBRINOGEN
Stephan Hornykewycz, Kirsten C. Odegard, Robert Castro, James A. DiNardo. Division of Cardiac Anesthesia, dChildrens Hospital Boston, Boston MA
Introduction: Hemostasis in infants and neonates following cardiac surgery can be problematic. We hypothesized that the composition and volume of the pump prime would in large part determine the coagulation prole during and following CPB. Methods: With informed consent and institutional approval 17 neonates and infants scheduled for primary cardiac surgical procedures were enrolled. The CPB prime volume was 300 mL with refrigerated whole blood 48 hrs old but 7 days old added to reach a target Hct of 35%. Continuous ultraltration was utilized. Transfusion of PRBCs and component therapy following CPB was at the discretion of the anesthesiologist. Concentrated platelets (25 mL/unit) were utilized. Paired t-tests were utilized with signicance at p .05 Results: Average age 141.4 day (range, 5357 days), average weight 5.27 kg (range, 3.2 8.3 kg). Following protamine reversal of heparin group N (n 6) received PRBCs, group P (n 8) received an average of 2.8 units platelets, and group PC (n 3) received an average of 3.9 units platelets and 3.9 units cryoprecipitate. For all 17 patients the average platelet count of the CPB prime was 5.7 K/uL. The average preoperative platelet count of 289 K/uL dropped signicantly to 116 K/uL at the onset of CPB. There was a signicant additional drop in platelet count as CPB progressed; the average platelet count was 79 K/uL just before the termination of CPB. For all 17 patients the average brinogen of the CPB prime was 133 mg/dL. The average preoperative brinogen of 246 mg/dL dropped signicantly to 165 mg/dL at the onset of CPB. Fibrinogen rose signicantly during CPB to192 mg/dL but remained signicantly lower than the preoperative average. Conclusions: Use of whole blood refrigerated for 48 hrs as a CPB prime in infants and neonates results in severe dilutional thrombocytopenia with less severe reductions in brinogen levels. Aggressive transfusion of concentrated platelets improves platelet count to near normal and also appears to improve brinogen levels presumably via transfusion of the FFP in which they are suspended.

Table. Plt Count (K/uL) PreCPB Group N Group P Group PC 249 312 313 CPB Prime 5 5.7 6.3 5 Mins on CPB 105 131 98 Rewarming CPB 74 97 70 Posttransfusion 151 205 249

Group N Pre-CPB to 5 mins CPB and 5 mins CPB to rewarming p .05. Group P Pre-CPB to 5 mins CPB, 5 mins CPB to rewarming, rewarming to posttransfusion, and Pre-CPB to posttransfusion p .05. Table. Fibrinogen (mg/dL) PreCPB Group N Group P Group PC 240 277 180 CPB Prime 113 148 106 5 Mins on CPB 160 179 127 Rewarming CPB 187 196 181 Posttransfusion 237 230 379

Group N Pre-CPB to 5 mins CPB p .05. Group P Pre-CPB to 5 mins CPB, 5 mins CPB to rewarming, and rewarming to posttransfusion, p .05.

12 PERIOPERATIVE EXTRACORPOREAL MEMBRANE OXYGENATION USE IN CHILDREN WITH CONGENITAL HEART DISEASE: IMPACT OF TIMING ON OUTCOME. Stacie B. Peddy, MD, Gregory H. Gorman, MD, Z. Leah Harris, MD Elizabeth A. Hunt, MD, MPH
Background: Extracorporeal membrane oxygenation (ECMO) is a mainstay of treatment for children with failing circulation from congenital heart disease in the perioperative period. Despite its increased use and the identied risk factors for survival, timing of ECMO utilization and its effect on outcome has not been examined. The purpose of this study is to examine the association between the timing of ECMO cannulation (preoperative vs. postoperative) and the survival status of pediatric cardiac surgical patients. Method of Investigation: This retrospective cohort study examined all neonatal and pediatric cardiac surgical patients managed with ECMO between June 1, 1989, and June 30, 2003, at a single institution. Medical records and our ECMO database were reviewed for the following clinical information: demographics, cardiac birth anatomy, indication for ECMO, timing of cannulation, pH and number inotropes infusing at cannulation, duration of ECMO, and occurrence of adverse events bacteremia, bleeding, intraventricular hemorrhage and need for renal replacement therapy. Surgical complexity and intraoperative times were recorded on the postoperative patients only. The clinical endpoints were survival at decannulation and at hospital discharge. Results: During the study period, 40 patients were managed with perioperative ECMO. For the entire cohort, 24/40 (60%) survived to decannulation and 12/40 (30%) survived to hospital discharge. The patients were stratied by timing of ECMO cannulation, 10/40 (25%) were supported preoperatively and 30/40 (75%) postoperatively. Preoperative patients were younger (median age, 1.5 days [range, 0 68 days] vs. 43.5 days [range, 0 5.9 yrs]; p .001) and weighed less (median weight, 2.95 kg [range, 2.33.9 kg] vs. 3.7 kg [range, 218 kg] p .02). The cardiac birth anatomy (two ventricle or single ventricle with or without arch obstruction)1 was not signicantly different between the groups, nor was the incidence of adverse events. Indications for ECMO varied significantly between the two groups. The primary indication for preoperative ECMO was pulmonary hypertension while postoperative ECMO was used most often after cardiac arrest (p .01). Hospital survival was signicantly higher for patients managed with preoperative ECMO vs. postoperative ECMO (6/10 [60%] vs. 6/30 [20%]; p .02). Further analysis of the 30 patients receiving postoperative ECMO was performed. Complexity of surgical procedure by risk category2 and intraoperative times were not associated with mortality rates. The duration of ECMO support and the incidence of adverse events was not signicantly different between postoperative ECMO survivors and nonsurvivors. However, postoperative patients who were placed on ECMO following a cardiac arrest had a lower pH at the time of cannulation (mean pH of 7.12 vs. 7.30; p .01) and had an increased probability of hospital death (mortality, 13/14 [93%] vs. 10/16 [63%] p .03) than the remaining postoperative cannulation patients. Conclusions: Patients who were placed on ECMO postoperatively had signicantly higher mortality rates than patients placed on ECMO preoperatively. In addition, postoperative patients placed on ECMO following cardiac arrest had signicantly higher mortality rates than the remaining postoperative cannulation patients. Studies to determine whether earlier institution of ECMO for children with congenital heart disease in the perioperative period can improve outcomes are warranted.

14 QRS DURATION FOLLOWING THE NORWOOD PROCEDURE: BLALOCK-TAUSSIG SHUNT VERSUS RIGHT VENTRICLE TO PULMONARY ARTERY SHUNT Eric M. Graham, Mark A. Scheurer, J. Philip Saul, Scott M. Bradley, Andrew M. Atz. Medical University of South Carolina, Charleston, SC
Background: A recent modication to the Norwood procedure involving a right ventricle to pulmonary artery shunt (RV-PA) has had favorable results at many institutions. Concerns remain regarding the required ventriculotomy. In other forms of congenital heart disease, the QRS duration from a standard surface electrocardiogram (ECG) has been shown to correlate well with right ventricular size. QRS prolongation has been shown to be a highly sensitive marker for sustained ventricular tachycardia and sudden cardiac death in adult patients with previous repair of tetralogy of Fallot. QRS prolongation has not been addressed in patients undergoing a Norwood procedure with an RV-PA shunt. Methods: We compared all 82 patients who underwent the Norwood procedure from January 2000 to February 2005 with a modied Blalock-Taussig shunt (BTS, n 41) vs. a RV-PA (n 41). ECGs were retrospectively reviewed at 1) pre-Norwood, 2) postNorwood, and 3) either pre-caval pulmonary anastomsis (CPA) or last recorded ECG if the patient expired before CPA. ECGs were compared between groups for QRS duration and any form of right bundle branch block or intraventricular conduction delay. Results: See table median (range). Conclusion: QRS duration was slightly longer post-RV-PA than BTS, but by pre-CPA the difference was no longer signicant. A ventriculotomy has minimal effects on QRS duration in the short term. Larger and longer longitudinal studies will be necessary to assess the long-term effects of a neonatal ventriculotomy on the conduction system.

Table. BTS Pre-Norwood QRS (ms) Post-Norwood QRS (ms) Pre-CPA QRS (ms) Pre-Norwood to post-Norwood QRS change (ms) Pre-Norwood to pre-CPA QRS change (ms) Post-Norwood to pre-CPA QRS change (ms) Patients with conduction delay (n) 62 (46 92) 60 (40 90) 82 (46 120) 4 (34 18) 12 (1254) 16 (12 42) 1 RV-PA 62 (50 100) 66 (48 112) 80 (56 144) 0 (24 56) 14 (20 56) 14 (1750) 4 p Value .43 .02 .54 .06 .32 .65 .36

REFERENCES
1. Clancy RR, et al: J Thorac Cardiovasc Surg 2000; 119:347357 2. Jenkins KJ, et al: J Thorac Cardiovasc Surg 2002; 123:110 118

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15 RECOMBINANT FACTOR VIIA FOR THE TREATMENT OF REFRACTORY BLEEDING IN POSTOPERATIVE PEDIATRIC CARDIAC PATIENTS ON ECMO Mercedes Villanueva Judkins, Jo Ellen Bennett, Randy Bartilson, Theresa Shalaby, Neal Patel, Frederick Barr, Mary B. Taylor
Purpose of Study: To evaluate the use of recombinant factor VIIa (rFVIIa) for the treatment of refractory postoperative bleeding in pediatric patients requiring extra corporeal membrane oxygenation (ECMO) after cardiac surgery. Setting: Pediatric cardiac critical care unit at a University Medical Center in Nashville, TN. Methods: We performed a retrospective analysis of pediatric cardiac patients with refractory postoperative bleeding on ECMO after cardiac surgery that required treatment with rFVIIa. We report 11 patients on veno-arterial (VA) ECMO with bleeding refractory to treatment with transfusions of packed red blood cells, platelets, FFP and cryoprecipitate who were treated with rFVIIa. Results: Patient diagnoses were HLHS (6), critical AS (1), TGA/VSD ( 2), TGA ( 1) and AVSD/TGA ( 1). All patients were placed on VA ECMO after failure to separate from cardiopulmonary bypass postoperatively. Median chest tube drainage was 49 mL/kg/hr 3 hrs before rFVIIa dose administration and 15 mL/kg/hr (p .003) 3 hrs after the rst dose of rFVIIa with a median percent difference pre- and post-drug of 70%. We show that 7/11 (64%) patients had 50% decrease in chest tube output after the rst dose of rFVIIa administration. 7/11 patients received a second dose of rFVIIa and had a median CT drainage of 3.45 mL/kg/hr (p .003) after the second dose of rFVIIa. 82% (9/11) patients showed 50% decrease in CT drainage after second dose. Blood product requirement was signicantly decreased after rFVIIa (Table 1). The mean dose of rFVIIa was 36 g/kg. Complications included clotting of ECMO circuit 7 hrs postadministration of rFVIIa in one patient and amputation of right lower limb in another patient who had hypotension and arterial line attempt in that extremity. Mortality was 45% in this patient group. Conclusions: Life threatening hemorrhage on ECMO can be treated with rFVIIa. rFVIIa can be effective in decreasing blood loss and blood product use with postoperative cardiac patients on the ECMO support. Further investigation is needed to determine if the use of rFVIIa increases thrombotic complications on ECMO.

16

TEMPERATURE MEASUREMENT AND CEREBRAL OXYGENATION OF INFANTS DURING AND AFTER CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS Katherine M. Bailey, MD,* Stuart Hall, MD,# Debora L. East, RN,# Charles D. Fraser, MD,## Anthony C. Chang, MD,### Dean B. Andropoulos, MD.# *Pediatric Cardiovascular Anesthesia, British Columbia Childrens Hospital, Vancouver BC Canada; #Pediatric Cardiovascular Anesthesiology, ##Congenital Heart Surgery, and ###Pediatric Cardiology, Texas Childrens Hospital, Baylor College of Medicine, Houston, TX
Introduction: Cerebral hyperthermia after cardiac surgery with cardiopulmonary bypass in children is common, and causes increased cerebral oxygen consumption which may lead to neuronal dysfunction and cell death.1 Brain temperature commonly exceeds rectal temperature by 1C in the early postoperative period.1 In the operating room, nasopharyngeal (NP) temperature is commonly used as a surrogate for brain temperature, but it is not used postoperatively to measure temperature. Regional cerebral oxyhemoglobin saturation (rSO2i), measured by near infrared spectroscopy, is inversely correlated with temperature in the operating room in these patients.2 In this study, we compared postoperative NP temperature to rectal temperature in infants and children undergoing cardiac surgery with hypothermic cardiopulmonary bypass, and also measured rSO2i in these patients. Our hypotheses were 1. NP temperature would exceed rectal temperature by 1C or more for at least 4 hrs in the rst 24 hrs in the intensive care unit, and 2. rSO2i would be negatively correlated with NP temperature during this period. Methods: Patients aged birth to 6 yrs undergoing cardiac surgery with hypothermic (28C or less) cardiopulmonary bypass were enrolled after IRB approval of the study and informed consent from a parent. In the postoperative period, NP and rectal temperatures, and rSO2i (Somanetics 5100B, Troy MI) were prospectively recorded for 24 hrs in 1-min intervals by a computerized data collection system. Rectal temperatures 38C were treated with acetaminophen and environmental measures per standard protocol. Data from all patients was pooled, and for each hour of data, mean and SD were calculated. NP and rectal temperatures were compared using t-test, with p .01 signicant. Pearson Correlation was used to assess the correlation between mean rSO2i and NP temperature for each hour of data, with values 0.2 signifying positive correlation, and 0.2 signifying negative correlation. Results: 16 patients were studied, with a mean age of 1.5 2.1 yrs and weight of 8.1 5.4 kg. Diagnoses included two-ventricle lesions undergoing complete anatomic repair in 13 patients, and single ventricle lesions undergoing staged palliative repairs in 3. Mean bypass time was 178 56 mins, and lowest temperature 23.0 4.3C. NP temperature was not signicantly higher than rectal temperature except at hours 1 and 17 (Fig. 1). Four of the 16 patients had NP or rectal temperatures 38.0C for 60 mins or more, and one patient had rectal and NP temp 39.0C for 60 mins, with maximum temperature 39.3C. These patients with elevated temperatures did not exhibit correspondingly lower rSO2i during those hours. rSO2i exhibited a statistically signicant positive correlation with NP temperature during hours 10 13, and a negative correlation during hours 17, and 20 24 (Fig. 2).

Table. Estimated blood loss Pre- and Post-rFVII Pre- Post-1stp Value rFVIIa Dose Median CT output,49 mL/kg/hr Blood product, Means PRBC (mL/kg) 175 Platelet (mL/kg) 18 FFP (mL/kg) 38 Cryoprecipitate10 (mL/kg/hr) 15 .003 Post-2ndp Value Dose 4 .003

150 9 16 1

.347 .091 .034 .011

30 5 2 5

.002 .037 .002 .093

Discussion: We designed this study with the concept that NP temperature may be more appropriate to measure postoperatively after pediatric cardiac surgery because it would more accurately reect brain temperature than rectal temperature would. Our data suggest that this is not the case, as rectal temperature was actually higher than NP temperature during almost all hours. The difference in temperatures is not clinically signicant, suggesting that rectal temperature is an adequate measurement site for all patients. Previous studies reveal that brain temperature is typically 1C or more higher than rectal, so temperature management protocols should take this into account. The inconsistent correlation of NP temperature with rSO2i suggests that there are many other factors determining rSO2i in these patients. The negative correlation in the last 8 hrs of the study suggests that temperature control measures will be useful to maximize brain oxygenation during this period.
Conclusions: Rectal temperature is an adequate site for temperature measurement in postoperative pediatric cardiac surgery patients. The determinants of rSO2i in the postoperative period are complex and deserve further study and analysis.

REFERENCES
1. Bissonnette B, Holtby HM, Davis AJ, et al: Cerebral hyperthermia in children after cardiopulmonary bypass. Anesthesiology 2000; 93:611 618 2. Andropoulos DB, Diaz LK, East DL, et al: Intraoperative cerebral oxyhemoglobin saturation in neonates undergoing cardiac surgery with cardiopulmonary bypass. Anesthesiology 2005; 103:A1376

Figure 1. Nasopharyngeal (NP) vs. rectal temperature. Data are expressed as means. NP higher than rectal (p .01; t-test); *rectal higher than NP.

Figure 2. Postoperative rSO2i. Data reported as means. positive Pearson Correlation 0.2 with NP temperature; -negative Pearson correlation 0.2.

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17 RESUSCITATION EVENTS AND OUTCOMES IN A LARGE PEDIATRIC CARDIOVASCULAR PROGRAM Scheurer M, Laussen PC. Childrens Hospital, Boston, Department of Cardiology
Background: The survival of pediatric patients who have a sudden cardiac arrest has been reported to be poor (1). However there may be differences in outcome depending on the patient population, site of resuscitation and system for resuscitation. A rapid deployment extracorporeal membrane oxygenation (ECMO) system for use during active resuscitation has been used effectively since 1996 at Childrens Hospital, Boston (CHB). To most effectively implement rapid deployment ECMO, and to make sure that staff with the appropriate skills and knowledge regarding the complexity of congenital heart disease were immediately available for all resuscitation events in the Cardiovascular Program (CVP), we developed a rapid response system (RRS) and multidisciplinary Resuscitation Review Committee (RRC) specically for the CVP in 2002. The goal of the RRC is to review all resuscitation events that occur in the clinical areas of the CVP, including the cardiac intensive care unit (CICU), catheterization laboratory (CL), cardiac operating room, cardiology ward, and cardiology outpatient clinics, establish an education and simulation program for all staff, and examine the conduct of codes, available resources, and issues regarding leadership, stafng and communication. Here we describe our experience. Methods: From October 2002 to September 2005, all patients for whom a cardiac code was called in the CICU, CL or cardiology ward, and patients who received chest compressions before or after bypass in the operating room were included for review. Demographic data, time, day of week, and site of each event resuscitation were recorded. Return of a persistent perfusing rhythm, successful perfusion via ECMO cannulation or death was recorded for each event. All patients successfully resuscitated were followed to death or discharge. Results: Within the cardiovascular program, 219 resuscitations were performed in 166 patients from October 2003 to September 2005; median age, 93 days (range, 1 day74 yrs), median weight 4.5 kg (0.75128 kg). One hundred twenty-eight resuscitations (58.5%) occurred in the cardiac intensive care unit, 48 (21.9%) in the catheterization laboratory, 28 (12.8%) on the cardiology ward and 15 (6.8%) in the operating room. 126 occurred from 7PM to 7AM or on Saturday or Sunday (57.5%). One hundred and forty-eight resuscitations resulted in the successful return of a persistent perfusing rhythm (67.5%), 45 resuscitations resulted in perfusion via ECMO cannulation (20.6%), and 26 resuscitation events ended with the death of the patient (11.9%). In total, 110 of the 166 patients survived to discharge (66.2%). Twenty-two of 43 patients whose resuscitation included ECMO survived to discharge (51.1%). Conclusions: Our RRS fullls one of the initiatives developed by the Institute for Healthcare Improvement 100K Campaign, which was started in 2004 to prevent avoidable deaths. Our experience indicates that a resuscitation system for children with cardiac disease that includes a dedicated rapid response cardiac team, the option of early cannulation to ECMO, dedicated system and regular event review, and educational and simulation training for staff can result in a higher survival rate when compared with published series from pediatric intensive care units.

19 PERIOPERATIVE RED CELL SALVAGE IN PEDIATRIC CARDIAC SURGERY S. Salam, D. Abrams, A. Kelleher, J. La Rovere. Departments of Paediatric Intensive Care & Anaesthesia, Royal Brompton & Hareeld NHS Trust, London, UK
Objective: In recent years blood transfusion has become a debated healthcare issue. To minimise exposure to infectious agents and reduce blood bank transfusion requirements, leukocyte ltration and perioperative red cell salvage (RCS) are increasingly used in pediatric patients. We hypothesized RCS would reduce the need for additional blood products in children following cardiopulmonary bypass (CPB). Methods: Patients undergoing routine or emergency cardiac surgery requiring CPB over a study period of 3 months were included prospectively in the analysis. Haemoglobin (Hb), platelet count, coagulation screen and heparin levels were performed before, immediately after surgery and 24 hrs later. RCS was performed in theatre according to surgical and anaesthetic preference. Red cells were salvaged from the surgical site, anticoagulated, washed and following resuspension in saline reinfused into the patient within 4 hrs. The incidence of postoperative bleeding (10 mL/kg/hr) was recorded as was the need for additional red blood cells, platelets and fresh frozen plasma (FFP). The need for blood products was at the discretion of the consultant intensivist. Statistical analysis was performed using paired and unpaired student t-tests and Chi squared methods. Statistical signicance was accepted as p .05. Results: 35 consecutive patients (34.54 43.55 months, 13.48 14.39 kg) were included in the analysis. A total of 17 infants 12 months were included, 9/24 who received RCS and 8/11 who did not (p .052). Cyanotic heart disease was seen in 40%. RCS was performed in 24 of 35 patients, who were signicantly older (44.2 44.1 vs. 13.6 25.5; p .02) and heavier (16.6 16.2 vs. 6.7 4.7; p .01). No difference was seen in the prevalence of cyanosis between the two groups. Postoperative bleeding was seen 21% who underwent RCS and 40% in those who did not (p .33). There was no difference between Hb, platelet count, prothrombin time or brinogen levels between the two groups before or after surgery. The need for additional red blood cells was signicantly reduced in those who received RCS, 37.5% vs. 91%, p .003, as was the use of FFP, 8.3% vs. 45.5%, p .02. There was no difference in the need for platelet transfusion (p .2). Discussion: In this study RCS was performed on 68.5% of children following CPB. RCS signicantly reduced the need for further blood and FFP transfusion, although this was not related to postoperative bleeding. This has important implications for both exposure to infectious agents and health economics. That children who underwent RCS were older and heavier may be related to the complexity of surgery and CPB in younger patients, although infants were represented in both groups. A further analysis of potential health and economic benets in a homogenous group is needed.

REFERENCE
1. Pollack MM, et al: Crit Care Med 1997; 25:19511955

18 VOLUME EXPANSION IN THE POSTOPERATIVE FONTAN PATIENT PREDICTS EXTENDED DURATION OF MECHANICAL VENTILATION AND CICU LENGTH OF STAY Joshua W. Salvin, MD, Ravi R. Thiagarajan, MBBS, Peter C. Laussen, MBBS. Cardiac Intensive Care Unit, Childrens Hospital Boston, Boston, Massachusetts
Purpose: We hypothesize that Fontan patients who require signicant volume expansion in the early postoperative period have extended duration of mechanical ventilation and prolonged length of stay in the cardiac intensive care unit (CICU). Methods: Patients undergoing Fontan operation at Childrens Hospital Boston during 20022004 were selected for analysis. Demographic, anatomic, intra-operative, and postoperative hemodynamic data were obtained from the electronic medical record. The volume of uid (crystalloid, colloid, and blood) administered for vascular expansion within the rst 12 postoperative hours was recorded. High and low uid volume groups were created based on the median value of uid used for postoperative expansion. The primary outcome variables: duration of mechanical ventilation and CICU length of stay (LOS) were compared between the high and low volume group using univarate analysis. A multivariable linear regression model was used to assess the association of a large uid requirement with the primary outcome variables after adjusting for potential demographic and hemodynamic confounders. Results: A total of 84 patients [median age, 2.7, (1 41) yrs] undergoing Fontan operation were studied. The median volume of resuscitation uid administered in the rst 24 postoperative hours was 59.2 cc/kg (5.8 142.7 cc/kg). Patients in the high volume group (n 42) were younger [median age, 2.64, (2 41) yrs vs. 2.82 (131) yrs; p .049], and had lower weight [median, 11.9 (8.8 82) kg vs. 13.0 (9.377.5) kg; p .021] compared with the low-volume group (n 42). Preoperative transpulmonary gradient and pulmonary vascular resistance did not signicantly differ between the high and low volume resuscitation groups, nor did the intraoperative cardiopulmonary bypass time, CICU admission lactate and central venous pressure. The high volume group had signicantly more chest tube (CT) drainage in the rst 12 postoperative hours [median, 35.9 (5.5117.32) cc/kg vs. 17.9 (0 44.9) cc/kg; p .001]. Patients in the high volume group required longer time of mechanical ventilation when compared with patients in the low volume group [median, 20 (8 1632) hrs vs. 15 (272) hrs; p .001). There was a trend toward longer CICU LOS in the high volume group when compared with the low volume group [median, 3.5 (1150) vs. 3 (1 41) days; p .08]. In multivariable analysis adjusting for patient age, weight, and volume of CT drainage, patients in the high volume group had signicantly longer duration of mechanical ventilation [ 1.69, (95% CI, 1.12.5)] and longer CICU LOS [ 1.7 (95% CI, 1.12.7)] when compared with the low volume group. Conclusions: The need for high volume resuscitation in the postoperative Fontan is associated with younger age, lower weight, and higher postoperative chest tube drainage. Pre- and postoperative hemodynamic variables were not predictive of the need for high volume resuscitation. In multivariable analysis, patients with high volume resuscitation required longer periods of mechanical ventilation and had longer CICU LOS. Further work is necessary to determine specic anatomic and hemodynamic risk factors for high volume replacement.

20 THE EFFECT OF POSITIVE END EXPIRATORY PRESSURE (PEEP) ON THE PULMONARY TO SYSTEMIC BLOOD FLOW RATIO (QP/QS) IN NEONATES WITH HYPOPLASTIC LEFT HEART SYNDROME (HLHS) E. Phillipos, S. Escoredo, M. Robertson, V. Rigo
Background: Neonates with single ventricle physiology require critical balance of pulmonary (QP) and systemic circulation (QS) to decrease the work of the single ventricle and prevent systemic underperfusion. QP/QS is determined by the vascular resistance in the respective beds and hence a high QP/QS is indicative of pulmonary overcirculation and a high arterial saturation 85%. Objectives: The use of nonconventional PEEP (8 or 4 cm H2O) to induce pulmonary hypertension in neonates with HLHS and QP/QS 1 will result in improved systemic perfusion and decrease use of inotropes. Methods: Neonates with HLHS (and aortic atresia) and arterial saturation 85% were randomized to low (4 0 cm H2O) or high ( 8 14 cm H2O) PEEP. PEEP was adjusted to achieve sat 75 85% and maintaining same tidal volume. Nonresponders or those who become unstable were crossed over to the other group. Vessel diameter and ow velocity integral in the main pulmonary artery (QMPA) and ductus arteriosus (QPDA) were obtained using 2D Echo before and 1 hr after PEEP changes. Similarly, Doppler ow velocity were performed in celiac (CA), superior mesenteric (SMA) and anterior cerebral arteries (ACA). Other data collected included inotropic score (INS), lactate (L), urine output (UO), systolic BP (SBP), gases, volume expansion and sodium bicarbonate. Calculation: QP QMMPA - QPDA, QPDA QS. Average velocity (AV) was calculated in CA, SMA, ACA. All measurements were recorded and later analyzed blindly by an independent investigator. INS, SBP, UO, L and sat were averaged 6 hrs prior and 6 hrs after nal PEEP reached. Results: Eight and nine neonates were randomized to high and low peep respectively. One neonate in low and three in high group were crossed over to other group. Results are mean SD. Conclusion: The use of low PEEP in babies with HLHS and high QP/QS results in decreased shunt fraction, decreased inotropic use and improved systemic perfusion with increased blood ow velocity in anterior cerebral artery and celiac axis. Although high PEEP resulted in signicant decrease in shunt fraction, there was no associated signicant changes to systemic perfusion.

Table. High PEEP (m 9) Before QP/QS INS SBP, mm Hg UO, mL/kg/hr L, mmol/L Sat, % AV, cm/sec CA SMA ACA *p .05 before and after. 3.6 1.1 6.5 7.2 58 7.3 2.8 1.1 1.8 0.4 88 3.0 33 11 11 2 17 5 After 2.1 0.5* 3.5 2.5 61 9.3 3.2 0.9 1.6 0.4 86 3.1 33 14 12 5 22 7 Low PEEP (m 12) Before 3.2 0.8 4.9 1.6 59 9.6 2.3 1.0 1.8 0.5 90 4.8 30 13 15 6 20 6 After 2.0 1.1* 1.3 1.0* 64 7.1* 4.7 1.0* 1.4 0.5* 78 6.0* 48 26* 18 8 26 6*

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21 ENERGY EXPENDITURE AND CALORIC INTAKE IN INFANTS FOLLOWING THE NORWOOD PROCEDURE Jia Li, Gencheng Zhang, Joann Herridge, Helen Holtby, Tilman Humpl, Christopher Caldarone, William G. Williams, Andrew N Redington, Glen S. VanArsdell
Objectives: Infants following cardiopulmonary bypass (CPB) are characterized by a hypermetabolic response. Nutrition is an important component in the care of these children as it supports their basal metabolic requirements and is necessary in preserving their body mass. Energy requirements of this unique group of surgical infants have not been well studied to date. We assessed EE and examined caloric intake in our current feeding approach in infants during the hours immediately postsurgery and 3 days following the Norwood procedure. Methods. Seventeen sedated, paralyzed, and mechanically ventilated infants were studied for the rst 72 hrs following the Norwood procedure. VO2 and VCO2 were continuously measured by respiratory mass spectrometry. The respiratory quotient (RQ) was determined as VCO2/VO2. EE was calculated using modied Weir equation. Measurements were collected at 2- to 4-hr intervals. The mean values in the rst 8 hrs, hours 8 32, and 3256, and the last 16 hrs were used as representative values for postoperative day 0, 1, 2, and 3. Infants total caloric intake was recorded for each day. Mixed linear regression analysis was used to determine the nature of time, trend of the measures over the 72 hrs. Results. EE, VO2, VCO2, showed wide inter- and intra-individual variations during the study period. They were initially high, declined rapidly during the rst 8 hrs, maintained relatively stable in the next 48 hrs, and increased signicantly in the last 16 hrs (p .0001) (Fig.). RQ showed a signicant linear increase over the 72 hrs (p .002). EE on day 0, 1, 2 and 3 was 43 11, 39 8, 39 8 and 41 6 kcal/kg/day, respectively. Total caloric intake was 3 1, 14 5, 31 16 and 51 16 kcal/kg/day, which is 8 4, 34 13, 74 41 and 119 47% of EE on day 0, 1, 2 and 3, respectively (Table). Conclusions: Hypermetabolic response occurs in infants during the immediate period after the Norwood procedure, with large intra- and inter-patients variations. Caloric intake in the current feeding approach is inadequate to meet the energy expenditure during the early days postsurgery. Further studies are warranted to examine the effects of caloric supplementation on postoperative outcomes in infants after CPB.

22 CLINICAL UTILITY OF CW DOPPLER ULTRASOUND FOR MEASURING CARDIAC OUTPUT (USCOM) Heerman, William J, Churchwell, Kevin B, Taylor, Mary B, Monroe Carell Jr. Childrens Hospital at Vanderbilt University, Nashville, TN
Purpose: To investigate the clinical usefulness of continuous wave (CW) Doppler ultrasound for monitoring cardiac function in a pediatric critical care setting by evaluating intra-user variability and the time necessary to obtain measurements. Methods: USCOM, Ltd. has developed a transcutaneous CW Doppler ultrasound device that measures blood ow across the semi-lunar valves. An ultrasound probe (3.3 MHz) is placed on the patients skin in the suprasternal notch or over the 4th intercostal space. The device plots the velocity of transvalvular blood ow against time. The velocity time integral (vti) is measured manually using the touch point feature on the device. The devices algorithm calculates cardiac output: C.O. vti cross-sectional area of the outow tract heart rate. We evaluated cardiac output in seven pediatric patients (5 yrs old) for 24 hrs following corrective heart surgery. At each of ten time points we used the USCOM device to record two sequential measurements using either the suprasternal approach (aortic valve) or the intercostal approach (pulmonic valve). Each measurement represents the average of four heartbeats. Thus, at each time point we recorded two equivalent representations of each patients cardiac output. Based on a global assessment of the quality of the traces obtained, we chose either the aortic or pulmonic traces to represent the overall trend of cardiac output for each patient. All measurements were taken by a single investigator who was previously untrained in CW ultrasound. Results: The average time to obtain the initial data measurement was 6.0 mins 3.17 mins. The average time to obtain each subsequent measurement was 1.75 mins 0.23 mins. The means and 95% condence intervals are presented. The Bland-Altman method (Fig. 1) evaluates the intra-user variation between the two sequential cardiac output measurements, which are taken at the same time point. The difference between each pair of measurements (y-axis) is plotted against the mean of each pair of measurements (x-axis). 65 of 68 data points fall within the 95% condence interval of the mean. Conclusions: The use of continuous wave Doppler ultrasound is a promising new technique for measuring cardiac output noninvasively. The Bland-Altman plot demonstrates low variability, especially at low cardiac output values. The greater variation at higher cardiac output values is explained partially by inter-patient variation but requires further investigation. With low intra-user variability and an average measurement time of 2 mins, the USCOM device proves to be a practical method of assessing cardiac status in a pediatric critical care setting.

Table. Postoperative Days VO2 (mL/kg/min) VCO2 (mL/kg/min) RQ REE (kcal/kg/day) Total caloric intake (kcal/kg/day) % of total caloric intake to REE Day 0 6.1 1.5 5.4 1.3 0.89 0.09 43 11 31 84 Day 1 5.4 1.1 5.1 1.0 0.93 0.10 39 8 14 5 34 13 Day 2 5.4 0.9 5.0 1.0 0.93 0.10 39 7 31 16 74 41 Day 3 5.6 0.8 5.4 0.8 0.98 0.09 41 6 51 16 119 47

Figure 1. Bland-Altman method: Differences in cardiac output vs. mean cardiac output at each time point. The mean is -0.04 L/min. The SD is 0.45 L/min. 65/68 data points are within the 95% condence interval (represented by the lines). This indicates a low level of intrauser variation.

23 FAMILY PRESENCE DURING INTERVENTIONS: PERCEPTIONS OF PEDIATRIC CARDIAC INTENSIVE CARE PROVIDERS Julie Kuzin, Anthony Chang, Gina Whitney, Jennifer Yborra, Antonio Mott Houston, TX
Purpose: Should family members be present during interventions (noninvasive and invasive) in an intensive care unit (ICU)? This issue is a source of spirited debate among healthcare providers in both adult and pediatric ICUs. This topic was the focus of an open-forum at the 2004 Pediatric Cardiac Intensive Care Symposium (PCICS). We propose to dene perceptions regarding family presence during ICU interventions from a multidisciplinary group of pediatric cardiac intensive care providers. Methods: A 20-question survey was created and distributed to attendees of the 2004 PCICS using an internet based serviceSurveyMonkey.com. Interventions were dened: noninvasive (physician rounds), invasive procedures (tracheal intubation, central/arterial line placement, chest tube placement, pericardiocentesis), and extremely invasive (cardiopulmonary resuscitation) (CPR). Results: A total of 100 surveys were completed by providers. The most common provider groups were intensivists (n 34), ICU nurses (neonatal and pediatric) (n 22), and anesthesiologists (n 15). The clinical experience (years) of the group was most commonly 10 yrs (46%). Formal Policy: Forty-ve percent of providers work in ICUs that allow family members to attend and participate in physician rounds; while with 29% of providers, family members cannot attend physician rounds. During invasive procedures, 63% of providers work in ICUs where family presence is determined by the physicians, and with 20% of providers, there is unrestricted access. With 13% of providers, there is a formal ICU policy that restricts family member presence during CPR, however with 52% of providers, the physician determines the appropriateness of family presence. Experiences: Regardless of intervention, the majority of providers feel that family members have a right to be present during interventions CPR (80%), physician rounds (80%), but lesser so with invasive procedures with only 56%. Most providers have witnessed positive experiences when family members were present during CPR (75%) and physician rounds (86%) but lesser so with invasive procedures (61%). Predictions: While 63% of providers support the idea of family presence during ICU interventions, family presence during invasive procedures may cause stress to the physician as noted with 86% of providers, moreover witnessing a CPR event could be stressful/traumatic to the family as noted with 43% of providers. Forty-six percent of providers predict that family presence during CPR would not increase medico-legal concerns, but 37% of providers were neutral on this issue. With 65% of providers, the presence of families during CPR would not lead to heroic efforts. And, the majority of providers did not feel that family presence overall would be obstructive to care as noted with 63% of providers. Conclusion: There is no consensus with regards to family presence during ICU interventions. Most providers feel that family members have a right to be present during, although it can be stressful to the providers during invasive procedures and to the family member who witnesses CPR. Most providers predict that family presence during interventions will not obstruct care delivery.

Pediatr Crit Care Med 2006 Vol. 7, No. 6 (Suppl.)

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