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There are limited studies describing the epidemiology and outcomes in children and young adults receiving continuous kidney replacement therapy (CKRT). We aimed to describe associations between patient characteristics, CKRT prescription, and survival.

The increase in pediatric cardiac surgical procedures and establishment of the practice of pediatric cardiac intensive care has created the need for physicians with advanced and specialized knowledge and training. Current training pathways to become a pediatric cardiac intensivist have a great deal of variability and have unique strengths and weaknesses with influences from critical care, cardiology, neonatology, anesthesiology, and cardiac surgery. Such variability has created much confusion among trainees looking to pursue a career in our specialized field. This is a report with perspectives from the most common advanced fellowship training pathways taken to become a pediatric cardiac intensivist as well as various related topics including scholarship, qualifications, and credentialing.

Introduction:Reintervention rate after percutaneous balloon valvuloplasty (BV) for critical congenital pulmonary valve stenosis (PS) is unknown.Hypothesis:Repeat BV or surgical intervention within 1 year of BV for critical PS is uncommon.Methods:The Pediatric Health Information Systems database was queried for patients admitted at ?3 days of age from 2004-2018 with a principal diagnosis of PS who received prostaglandin and underwent primary BV. Study data included demographic variables, resource utilization (e.g. length of stay, ECMO use, etc), and reintervention during either the index hospitalization or a subsequent readmission to the index hospital within 1 year. Freedom from reintervention or death was assessed with Kaplan-Meier analysis, and risk factors were examined with multivariate analysis.Results:Balloon valvuloplasty was the principal procedure for critical PS in 1014 patients (53% male) from 49 hospitals (Table). Reintervention occurred in 4.6% (47/1014) during the index hospitalization (32 BV and 15 operative). On readmission, 44 patients (4.3%) underwent reintervention at a median of 81 (IQR: 54,144) days after initial BV. Among patients with reintervention during the index hospitalization, 17% (8/47) also underwent reintervention during a readmission. In-hospital mortality was 1.3% during the study. Freedom from death or reintervention was 91% at 1-year. Male sex was the only risk factor predictive of reintervention (OR: 2.1; 95% CI: 1.2-3.5; p=0.009).Conclusions:Reintervention for critical PS was not uncommon at 1-year in this large, retrospective multicenter study. Male sex is associated with increased rate of reintervention.

Introduction:Although fetal presentation of coarctation of the aorta (CoA) varies in severity, postnatal management is typically uniform and results in unnecessarily aggressive postnatal management for many infants.Hypotheses:A fetal risk-stratification protocol would 1) classify fetuses according to the likelihood of neonatal CoA surgery and 2) reduce unnecessary perinatal management in infants without surgical CoA.Methods:Protocol fetuses were prospectively stratified over 1 year, and compared to retrospectively stratified historical controls. Those with anatomic and physiologic findings suggestive of CoA were deemed ?high risk? for postnatal CoA, those with only anatomic features were ?moderate risk?, and those with minor supportive findings were ?slightly increased risk? (Table).Results:Excluding 9 terminations or demises, there were 32 protocol and 34 control fetuses. Increasing risk category was associated with more frequent surgical CoA (p<0.01) (Table). One infant in the high risk group was diagnosed with a normal arch, and 1 in the slightly increased risk group with surgical CoA. Surgical rate was similar between moderate (32%) and high risk groups (56%) (p=0.21) (Table). In cases without surgical CoA, location delivery change reduced from 57% in control fetuses to 23% in protocol fetuses (p=0.02), and initial NPO orders were reduced from 71% in control infants to 33% in protocol infants (p=0.05). Central lines, prostaglandin use, number of postnatal echocardiograms, and hospital and ICU days were similar between protocol and control subjects.Conclusions:This pilot study of the CoA protocol demonstrated that it appropriately risk stratified fetuses, although refinement is needed to distinguish between moderate and high risk groups. In well infants and non-surgical CoA, the protocol reduced the proportion of delivery location changes and initial NPO orders, although central line and echocardiogram rates did not change significantly.

Introduction:Most patients with anomalous left coronary artery from the pulmonary artery (ALCAPA) present in the first year of life. A minority is diagnosed at an older age; there is a paucity of data describing the presentation and outcomes of this subset.Hypothesis:Patients diagnosed ?1 year of age with ALCAPA present with different clinical symptoms and have different postoperative outcomes than patients diagnosed <1 year of age.Methods:We included all patients undergoing ALCAPA surgery between 1/2009 - 3/2018 at 20 Collaborative Research from the Pediatric Cardiac Intensive Care Society (CoRe-PCICS) centers. Study variables were extracted from the medical record. Clinical presentation and postoperative outcomes of patients diagnosed ?1 year of age were compared with patients diagnosed <1 year of age using chi-square, Fisher Exact, independent-t, or Mann-Whitney U tests.Results:Of the 221 ALCAPA patients, 72 (33%) were diagnosed ?1 year of age. Among this subset, the median age at diagnosis was 7.8 (25th%, 75th%iles; 2.3, 15.8) years (Table). Older patients were more likely to present with cardiac arrest (11% vs 1%) and less likely to have moderate-to-severe left ventricle (LV) dysfunction (22% vs 77%) or mitral regurgitation (19% vs 56%; p<0.001 for each). Compared to patients diagnosed <1 year of age, the older subset had less postoperative ECMO use (0% vs 17%) and shorter ICU and hospital LOS (p<0.001 for each) and similar operative mortality (1% vs 4%; p=0.43). In the older cohort, there was no outpatient mortality during a median follow-up of 3 (0.25, 6) years and LV function was normal to mildly depressed in 41/44 (93%) patients on 1-year follow-up echo.Conclusions:In this large multi-center cohort, patients with a diagnosis of ALCAPA ?1 year of age were more likely to present with cardiac arrest and less likely to have LV dysfunction than those diagnosed < 1 year of age. Survival was excellent and most patients had good LV function at 1-year follow-up.

Introduction:Patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) may have elevated blood oxygen tension during surgery. In other settings, hyperoxia (HO) has been associated with adverse outcomes in critical illness. Data are not available regarding the association of HO and outcomes in infants undergoing CPBHypothesis:Among infants undergoing cardiac surgery, HO during CPB is associated with an increased risk of morbidity and mortality.Methods:This was a retrospective single-center study at an academic tertiary children?s hospital. All infants (<1 year) undergoing CPB between 1/ 2015 - 12/2017 were included. Medical records were reviewed for patient characteristics, operative variables (including average partial arterial pressure of oxygen (PaO2)) and outcomes. The PaO2 with maximal sensitivity (75%) and specificity (50%) for operative mortality was identified using receiver operating characteristic curves. Univariate and multivariable logistic regression analysis were performed using appropriate statistics.Results:The study included 471 infants with a median age of 97 (15, 179) days, weight 4.85 (3.4, 6.36) kg, and CPB time 129 (91, 185) min. A PaO2 of 313mmHg on CPB had optimal discriminatory ability for operative mortality. Infants with PaO2 >313mmHg were more likely to have AKI, postoperative length of stay (PLOS) and mortality (Table). They were younger, weighed less, had longer CPB times, and higher STAT surgical severity scores. There was no difference in sex, race, preoperative creatinine, single ventricle physiology, or presence of genetic syndrome. When co-variables were controlled, PaO2>313 was associated with an adjusted odds ratio for mortality of 3.31 (1.19, 9.25), but did not predict AKI or PLOS.Conclusion:Hyperoxia was an independent risk factor for mortality among infants undergoing cardiac surgery on CPB. Future prospective evaluation of HO is necessary to determine causation of poor outcomes.