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Author(s): Aparna Hoskote [sup.1], Brigitte Stiller [sup.2], Ravi R. Thiagarajan [sup.3] Author Affiliations: (1) grid.424537.3, 0000 0004 5902 9895, Cardiac Intensive Care Unit, Heart and Lung Directorate, UCL, Great Ormond [...]

Author(s): Graeme MacLaren [sup.1] [sup.2], Katherine L. Brown [sup.3], Ravi R. Thiagarajan [sup.4] Author Affiliations: (1) grid.410759.e, 0000 0004 0451 6143, Cardiothoracic Intensive Care Unit, National University Health System, , [...]

Author(s): Graeme MacLaren [sup.1] [sup.2], Kate L. Brown [sup.3], Ravi R. Thiagarajan [sup.4] [sup.5] Author Affiliations: (1) grid.412106.0, 0000000406219599, Cardiothoracic Intensive Care Unit, National University Hospital, , 5 Lower Kent [...]

Byline: Thomas V. Brogan (1), Ravi R. Thiagarajan (2), Peter T. Rycus (3), Robert H. Bartlett (4), Susan L. Bratton (5) Keywords: Extracorporeal Life Support Organization (ELSO); Acute respiratory distress syndrome (ARDS); Pneumonia; Survival; Complications Abstract: Objective To evaluate clinical and treatment factors for patients recorded in the Extracorporeal Life Support Organization (ELSO) registry and survival of adult extracorporeal membrane oxygenation (ECMO) respiratory failure patients. Design and patients Retrospective case review of the ELSO registry from 1986--2006. Data were analyzed separately for the entire time period and the most recent years (2002--2006). Results Of 1,473 patients, 50% survived to discharge. Median age was 34 years. Most patients (78%) were supported with venovenous ECMO. In a multi-variate logistic regression model, pre-ECMO factors including increasing age, decreased weight, days on mechanical ventilation before ECMO, arterial blood pH a$? 7.18, and Hispanic and Asian race compared to white race were associated with increased odds of death. For the most recent years (n = 600), age and PaCO.sub.2 aY= 70 compared to PaCO.sub.2 a$? 44 were also associated with increased odds of death. The two diagnostic categories acute respiratory failure and asthma compared to ARDS were associated with decreased odds of mortality as was venovenous compared to venoarterial mode. CPR and complications while on ECMO including circuit rupture, central nervous system infarction or hemorrhage, gastrointestinal or pulmonary hemorrhage, and arterial blood pH < 7.2 or >7.6 were associated with increased odds of death. Conclusions Survival among this cohort of adults with severe respiratory failure supported with ECMO was 50%. Advanced patient age, increased pre-ECMO ventilation duration, diagnosis category and complications while on ECMO were associated with mortality. Prospective studies are needed to evaluate the role of this complex support mode. Author Affiliation: (1) Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA (2) Department of Cardiology and Pediatrics, Children's Hospital, Harvard Medical School, Boston, MA, USA (3) Extracorporeal Life Support Organization, Ann Arbor, MI, USA (4) Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA (5) Department of Pediatrics, Primary Children's Medical Center, University of Utah, Salt Lake City, UT, USA Article History: Registration Date: 09/09/2009 Received Date: 14/01/2009 Accepted Date: 27/07/2009 Online Date: 22/09/2009

Byline: Margarita K. Burmester (1,3), Roger Dionne (2), Ravi R. Thiagarajan (1), Peter C. Laussen (1) Keywords: Medication error; Cardiac intensive care unit; Paediatric; Computerized; Adverse drug event; Prescribing error Abstract: Objective To identify and reduce medication-prescribing errors by introducing systematic physician education and post-cardiac surgery admission prescription forms. Design Errors were defined as: incomplete prescriptions potential adverse drug events (ADEs), i.e. either intercepted or non-intercepted incorrect prescriptions not resulting in an ADE and incorrect prescriptions that resulted in ADEs. Two baseline blinded pre-intervention data collection periods of 4 weeks and 1 week were followed by implementation of a post-cardiac surgery templated physician order and prescription form and systematic physicians' education. Twelve post-intervention data collections of 1-week duration were completed over a 3-year period and were either blinded or informed with reinforcement of physicians' education. Setting Tertiary paediatric cardiac intensive care unit. Results A total of 3648 prescriptions were evaluated at baseline (meana-+-a-SD of 687a-+-a-8 per week) and 811a-+-a-129 prescriptions during each post-intervention period. Total baseline errors of 16.8% decreased to 8.4% after the first blinded data collection and to 4.8% at the final data collection (pa- Conclusion The incidence of incomplete prescriptions significantly improved with education of physicians and use of post-cardiac surgery templated physician order and prescription forms. There was no impact on potential ADEs. Author Affiliation: (1) Department of Cardiology, Children's Hospital, Boston, MA, USA (2) Department of Pharmacy, Children's Hospital, Boston, MA, USA (3) Paediatric Intensive Care Unit, Royal Brompton Hospital, Sydney Street, SW3 6NP, London, UK Article History: Registration Date: 20/02/2008 Received Date: 24/05/2007 Accepted Date: 18/02/2008 Online Date: 15/03/2008 Article note: Electronic supplementary material The online version of this article (doi: 10.1007/s00134-008-1054-3) contains supplementary material, which is available to authorized users.

OBJECTIVE. The objective for this study was to characterize the impact and the safety of transporting neonates with known or suspected cardiac abnormalities. METHODS. We reviewed retrospectively the charts and computerized records of 192 admissions to a cardiac ICU in 2002. Patients were included when they were RESULTS. Of local admissions, 31 (44%) patients had 61 suboptimal arrival values, including pH CONCLUSIONS. Although we did not encounter major transport complications, opportunities exist to optimize arrival status and improve surveillance and documentation. Key Words congenital heart defects, transportation of patients, cardiac surgical procedures, cardiac care facilities Abbreviations CHB--Children&apos;s Hospital Boston RACHS-1--Risk Adjustment for Congenital Heart Surgenj-1 APV--absent pulmonary valve CAVC--complete atrioventricular canal, PROPONENTS OF REGIONALIZATION of health care delivery argue that concentrating highly technical and infrequently performed medical procedures in a few geographically selected centers results in improved outcome, lower morbidity, and [...]

Byline: Ravi R. Thiagarajan (1), Stephen J. Roth (1), Steven Margossian (2), Andrew S. Mackie (1), Ellis J. Neufeld (2), Peter C. Laussen (1), Joseph M. Forbess (3), Elizabeth D. Blume (1) Keywords: Dilated cardiomyopathy Extracorporeal membrane oxygenation Hemophilia A Factor VIII inhibitor Cardiac transplantation Abstract: Objective. To report the use of extracorporeal membrane oxygenation (ECMO) as a bridge to cardiac transplantation in a patient with hemophilia A and dilated cardiomyopathy. Design. Case report. Interventions and results. During ECMO factor VIII concentrate was administered to maintain a factor VIII level close to 50% of normal control both to decrease the risk of bleeding and to allow standard anticoagulation with heparin. The patient developed an inhibitor to exogenous factor VIII during hospitalization, which was successfully managed with a high-dose continuous infusion of factor VIII during ECMO, the transplant operation, and the postoperative period. Conclusions. We report the successful use of ECMO as a bridge to cardiac transplantation in a patient with hemophilia A and low-level factor VIII inhibitors. Author Affiliation: (1) Department of Cardiology, Children's Hospital Boston, 300 Longwood Avenue, 02115, Boston, MA, USA (2) Division of Hematology, Children's Hospital Boston, 300 Longwood Avenue, 02115, Boston, MA, USA (3) Department of Cardiovascular Surgery, Children's Hospital Boston, 300 Longwood Avenue, 02115, Boston, MA, USA (4) Departments of Pediatrics and Surgery, Dana Farber Cancer Institute, Harvard Medical School, 02115, Boston, MA, USA Article History: Received Date: 06/02/2003 Accepted Date: 13/03/2003 Article note: Electronic Publication

Objective. Severe pneumococcal infections have been associated with hemolytic uremic syndrome (HUS), usually with a poor clinical outcome when compared with Escherichia coli O157 gastroenteritis--associated (D+) HUS. We examined our experience with 12 cases of Streptococcus pneumoniae-associated HUS (SP-HUS) and compare it with a cohort of diarrhea-associated HUS (D+ HUS). Methods. A retrospective case survey compared 2 unrelated groups of HUS patients. Demographic factors, clinical indices of disease severity, and outcome were used to compare the 2 groups of HUS patients. Results. Twelve children with SP-HUS were studied. Pneumococcal pneumonia with empyema was the most common precipitating illness (67%), pneumococcal meningitis was present in 17% of children, pneumonia with bacteremia in 8%, and both pneumonia and meningitis in 8%. SP-HUS patients were younger than D+ HUS patients (22.1 vs 49 months) and had more severe renal and hematologic disease than D+ HUS patients. Compared with D+ HUS patients, SP-HUS patients were more likely to require dialysis (75% vs 59%) and had a longer duration of hospitalization (33.2 vs 16.1 days) and duration of thrombocytopenia (11.6 vs 6.8 days). SP-HUS patients were also more likely to require platelet transfusions (83% vs 47%) and needed more platelet (4.7 vs 0.5) and packed red blood cell transfusions (7.8 vs 2.0). The 2 groups did not differ significantly in the incidence of extrarenal HUS complications. There were no deaths in either group. Seven patients have been seen for long-term follow-up; 2 developed end-stage renal disease, and 5 have normal renal function. Conclusions. HUS is a rare but severe complication of invasive pneumococcal infection. Although disseminated intravascular coagulation can also occur in these children, the treatment and follow-up may be different in the 2 conditions. Children with pneumococcal disease and severe hematologic or renal abnormalities should be investigated for evidence of HUS. Pediatrics 2002;110: 371-376; hemolytic uremic syndrome, Streptococcus pneumoniae, empyema, acute renal failure, meningitis, pneumonia, pediatric., ABBREVIATIONS. HUS, hemolytic uremic syndrome; D+ HUS, diarrhea-associated hemolytic uremic syndrome; DIC, disseminated intravascular coagulation; SP-HUS Streptococcus pneumoniae-associated hemolytic uremic syndrome; T-antigen, Thomsen-Freidenreich antigen; FFP, fresh-frozen plasma; ESRD, end-stage renal [...]