C-CHEWS Early Warning in Ped Cardiology

Most cardiopulmonary arrests in hospitalized children can be prevented by early recognition and treatment for signs of deterioration. Nurse researchers at Children’s Hospital Boston developed and validated the Cardiac Children’s Hospital Early Warning Score (C-CHEWS) for pediatric cardiology patients.

The score divides patients into one of three groups: routine care, increased assessment/intervention, or coronary intensive care unit (CICU) consult/transfer. A retrospective review of patients admitted to the cardiac unit over a 12-month period compared 64 patients who experienced arrest or an unplanned CICU transfer with a comparison group of 248 non-event admissions. When compared with the previously validated Pediatric Early Warning Score (PEWS) tool, the C-CHEWS had greater sensitivity. Overall, C-CHEWS showed excellent discrimination for identifying deterioration in children with cardiac disease. 

Despite Short-Term Problems with ECMO, Only Mild Disability Seen at Age 2

Extracorporeal membrane oxygenation (ECMO) is used for both cardiac and respiratory oxygen support for patients whose heart and lungs are severely diseased or damaged. Despite established efficacy in children with cardiac disease, reported survival after ECMO support remains suboptimal at 40% to 55%.

Are there ways to improve survival? Recognizing that ECMO survivors are at risk for significant neurologic injury, investigators surmised that an interdisciplinary team is crucial to prevention and follow-up. In a single-center retrospective review, investigators evaluated the outcomes of 95 children with congenital cardiac disease who required ECMO support between 2005 and 2010. Sixty-nine patients (73%) survived to hospital discharge.

Evaluation occurred at time of hospital discharge and at a median of almost 2 years follow-up. The indications for ECMO were cardiopulmonary resuscitation refractory to conventional resuscitation (E-CPR), failure to separate from cardiopulmonary bypass, and low cardiac output syndrome. Among the 69 survivors, 64% had cardiac surgery before ECMO, 19% had single ventricle, 55% two ventricles, 22% primary myocardial disease, and 4% primary pulmonary hypertension.

At time of hospital discharge 75% of the patients had either normal or mild neurologic disability. At 2 year follow-up 63 patients (66%) were still alive and normal to only mild neurologic disability was seen in more than 80% of these children. Patients with E-CPR, cerebral infarct or hemorrhage and patients who needed plasma exchange had worse short-term neurologic outcome, whereas worse long-term neurologic outcome was seen only in patients who suffered cerebral infarct.

While a majority of patients with some neurologic disability early on were significantly better at follow-up, about 5% were much worse at 2 years.

The researchers concluded that it is possible to improve survival and neurologic outcomes after pediatric cardiac ECMO, but it requires a sustained interdisciplinary team.  Also, follow-up is important because a small percentage of these very young patients will deteriorate significantly and dangerously over time.

ICU Scoring System Standardizes Transfer of High-Risk Shunted Newborns

Decisions to transfer neonates with shunted single ventricle physiology out of the ICU currently rely on variable criteria. Premature discharges result in unplanned readmissions and out-of-ICU cardiopulmonary arrests, while deferred transfers unnecessarily prolong the ICU stay.

Nurse-researchers at Children’s Medical Center Dallas developed an objective scoring system for postoperative single ventricle patients. Factoring into the discharge score were clinical variables such as post-operative echo results, weight, feeding regimen, respiratory support level, anti-platelet therapy, and family readiness. Static variables such as decreased ventricular function and arrhythmia were also taken into account.

Based on a retrospective review of patient charts, a discharge score of 10 or less predicted cardiopulmonary arrest or unplanned readmission. Higher discharge scores predicted extended CICU stays, with the maximum score being 18. The study team proposes that a score of 12 predicts a patient suitable for transfer from the CICU to the ward, and suggests that the discharge scoring system provides an objective method to help standardize practice for single-ventricle patients.  

Keywords: Survivors, Follow-Up Studies, Cardiopulmonary Resuscitation, Hypertension, Pulmonary, Ventricular Function, Cardiopulmonary Bypass, Cardiac Surgical Procedures, Cardiac Output, Low

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