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Point of care testing: improving pediatric outcomes
1Cardiac Intensive Care Program, Miami Children's Hospital, Miami, FL 33155, USA. anthony.rossi@mch.com
Insights
Goal-directed therapy combined with point-of-care testing significantly reduced mortality in pediatric congenital heart surgery patients. This approach showed the greatest benefit in the youngest and highest-risk surgical groups.
Area of Science:
- Pediatric Cardiac Surgery
- Critical Care Medicine
- Point-of-Care Testing
Background:
- Goal-directed therapy (GDT) is established for reducing critical illness mortality.
- Point-of-care testing (POCT) offers rapid results but lacks outcome data.
- Impact of GDT and POCT on congenital heart surgery outcomes is unevaluated.
Purpose of the Study:
- To evaluate the combined impact of GDT and POCT on mortality in pediatric congenital heart surgery patients.
- To assess if this combined strategy improves outcomes in high-risk and young patient populations.
Main Methods:
- Prospective incorporation of i-STAT POCT for lactate monitoring post-congenital heart surgery (July 2001).
- Serial lactate measurements guided therapy adjustments over 24 hours.
- Comparison of 30-day mortality between GDT+POCT group (n=378) and historical controls (n=851) using RACHS-1 risk scoring.
Main Results:
- Overall 30-day mortality decreased significantly in the GDT+POCT group (2.4% vs. 6.2%, P < 0.007).
- Neonatal mortality saw a significant reduction (4.3% vs. 12%, P = 0.008).
- Highest-risk surgeries (RACHS-1 groups 5+6) showed a 70% mortality reduction (9% vs. 30%, P = 0.03).
Conclusions:
- The combination of GDT and POCT significantly reduces mortality in pediatric congenital heart surgery.
- The benefits are most pronounced in neonates and patients undergoing high-risk procedures.
- This integrated approach represents a significant advancement in post-operative care for this population.
Objective:
Goal-directed therapy (GDT) has been proven to reduce morbidly and mortality in critical illness. Point of care testing (POCT) allows rapid turn around time (TAT) of critical data, yet data suggesting improved outcomes are very limited. The impact of these two strategies on improving outcomes for patients after congenital heart surgery has never been evaluated.
Design:
Beginning July 2001, POCT in the form of the i-STAT handheld analyzer was incorporated in the management of patients after congenital heart surgery at our institution. Blood lactate measurements were performed serially for 24 h after surgery. Based on a lactate value, medical therapy was escalated, diminished or left unchanged after surgery. Outcome data were collected prospectively for later review. Mortality at 30 days after surgery was compared for patients undergoing a GDT protocol to a group of historical cohorts. The operative risk for all operations was determined using the RACHS-1 scoring system.
Setting:
A 16-bed Cardiac Intensive Care Unit (CICU) in a 268-bed free-standing pediatric hospital.
Patients:
Outcomes of infants and neonates operated on from July 2001 through July 2003 (Group B) were compared to historical controls in our institution from June 1995 through June 2001 (Group A). There were 851 patients in Group A and 378 patients in Group B. Patients in Group B were smaller and younger than those in group A (median weight 3.8 vs. 4.3 kg, P < 0.001; median age 42 vs. 76 days, P = 0.02).
Measurements And Results:
Overall mortality was lower for Group B as compared to Group A (2.4% vs. 6.2%, P < 0.007). Significant reduction in mortality between Group B and Group A was noted in neonates (4.3% vs. 12%, P = 0.008) but did not reach significance in infants (0.9% vs. 2.6%, P = NS). Patients undergoing the highest-risk operations (RACHS-1 groups 5 + 6) had a 70% reduction in mortality when comparing Group B to Group A, (9% vs. 30%, P = 0.03), but no statistical difference in mortality was noted in those patients undergoing lower-risk operations (RACHS-1 groups 1 and 2, Group B 0.5% vs. Group A 1.5%, P = NS).
Conclusions:
The combination of goal-directed therapy and point of care testing significantly reduced mortality in patients undergoing congenital heart surgery. This improvement is greatest in the youngest patients and those undergoing higher-risk surgeries.
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