Stay Current Journal Club: Episode 1 - Ventricular Dysfunction in CDH and...

Hey there listeners, this is Rod from Cincinnati Children's. If you haven't already, download the Stay Current in pediatric surgery app. We've got a brand new layout, brand new content, but the reason I'm bringing it up for this podcast is because if you're listening to the podcast in the app, you can click on the links below the media player, and open up the journal articles that we're going to talk about in this episode. So you could follow along, check out the abstract, pause it and look at their tables, figures, graphs. Follow along with us and. Maybe you guys have your own opinions. You could even comment on the podcast in the app. So Download it now. It's in the Apple App Store. It's in the Google Play Store. But until then, Enjoy the episode. Whether you're a medical student or a pediatric surgical attending or anything in between. It's tough to stay on top of the literature. So a lot of times residency programs or surgical departments will have journal club. We get around, talk about a few articles that might be important for learning or for our own surgical practice. In today's episode, Todd and I want to try something different. We want to bring Journal Club to you. So that you can brush up on some literature while you're on your drive to work, or walking in the scrub machine to get started with your day. To do this, I brought in some help from some of my friends across the country. So, without further ado, here is your shortened, abbreviated journal club with me. Vic and Joe. Enjoy. Awesome. All right. So, welcome to the first episode of Stay Current Journal Club. I'm Rod from Cincinnati Children's, and we have, of course, with me always is Doctor Todd Ponsky, also from Cincinnati Children's. But we have some special guests here as well that I want to give them a second to say hi. So why don't we go round-robin here for me. The next one that I see here is Joe. Joe, why don't you go ahead and tell us about yourself and where you're from? Hey, Rob. Thanks for having me today. Uh, my name is Joe La Hillier. I'm one of the general surgery interns at the University of Buffalo. Excited to be here. Joe looks as organized as he sounds. His room looks really clean on the Zoom call, and he's wearing a plaid, button-down shirt, Buffalo Bills colors. I imagine it's freezing in Buffalo, but I can't be sure. Yeah, so, uh, I'm Vic, uh, I'm a PGY4 resident out of UT Southwestern in Dallas, doing a couple of years in the lab at UT Houston McGovern Medical School, studying diaphragmatic hernia. Thanks for having me. Vic is in his garage because his wife has some more important Zoom calls than we had. I mean, like Job interviews. But don't feel bad for him. He's in Texas, so he showed us out his window and it definitely looks warmer there. Awesome. Well, thank you guys for being here. I really appreciate it. I know, uh, everyone's busy, whether you're in the lab or your clinical, but there's always time for journal clubs. So, we'll kick it off. I chose an article uh that's near and dear to my heart. I'm studying diaphragmatic hernia in the lab. I've been doing that for the last couple of years. The article I chose is called Ventricular Dysfunction is a Critical determinant of mortality and congenital diaphragmatic hernia. So, if you're in the app, scroll down a little bit, look at that link. That is the article that Vic is talking about. Click on it. This is a December 2019 paper in American Journal of Respiratory and Critical Care Medicine. The first author is Neil Pattel, who's a neonatologist out in Glasgow. The senior author, is Doctor Harding, my PI down at UT Houston. But really, this is work from the congenital diaphragmatic hernia Study Group, and this is what I consider to be one of the foundational papers in the role of the heart and CDH. So, Um, what this group did is they took patient data from the CDA study group over the last five years. They did the study period 2015 to 2018, so it's a retrospective review of prospectively collected data. So what was the primary outcome? Uh, survival to discharge, and what they looked for is early cardiac dysfunction. So cardiac dysfunction on an echo within the 1st 48 hours of life and how that correlates with outcomes. The patients got split up into 4 groups, patients that had normal ventricular function, patients that had only right ventricular dysfunction, patients that had only left ventricular dysfunction, and then patients that had biventricular dysfunction on their first echo. Interesting. OK, so all these CVH patients got echoes, broke them down into the type of dysfunction. So what did they find? Uh, amongst all comers in the CDH study group through the study period, nearly 40%, 39% of patients had some evidence of cardiac dysfunction on their first echogram in the 1st 48 hours of life. Um, and from there, the cardiac dysfunction, uh, was an independent predictor of mortality and outcomes. So for patients with normal cardiac function on the adjusted analysis, they had a survival of over 80%. Then patients with right ventricular dysfunction only had a survival of 74%, left ventricular is 57%, and then predictably, if you had dysfunction in both ventricles, your survival was all the way down to 50%, the worst risk profile. OK, but don't those patients also have other risk factors for mortality? So even when adjusting for liver position, defect size, and, and other, other important variables, cardiac dysfunction was still a significant driver mortality. Um, and it really set the tone for what is one of the next fields in CDH that we need to start investigating. It may not just be a pulmonary disease. That's what I took away from this article. OK, so how is this going to affect patient care though? The the authors really push for the importance of evaluating early cardiac function in CDH patients. So get an early echocardiogram in the 1st 48 hours of life and then use some of their outcome profiles to stratify, is this patient high, high risk? Do they have a better chance of survival? Do we need to think about early ECMO, what type of ECMO, what medications do we need to do. The other thing is be multidisciplinary, get your neonatologists, surgeons, if you have a Cardiology team that sees the neonates get them involved. Yeah, Vic, I have a question for you. Yeah, so they talk about how there's no standard definition for right ventricular, left ventricular dysfunction, and I actually didn't see them list what their operational definition was in the paper. I'm not sure if I missed it. The CDH study group tries not to be very prescriptive. They try, they don't tell any institutions, this is how we're standardizing management and wants you to report. And, and literally on the data collection tool, it says, early echo done and what day, and then cardiac dysfunction or right ventricular dysfunction, yes or no. And if yes, was it systolic or diastolic? Just to give the potential interns like me listening on the call, people who might not have as much exposure to this topic. In general, what are we looking at when we say dysfunction? Yeah, so that's actually a really great question. And so pulmonary, like I said, pulmonary hypertension is a. of mortality for CDH infants. So what you see with that is you can see decreased right ventricular ejection, OK? That can in turn over time lead to bowing of the septum, OK, into the left ventricle, and so you'll see decreased ventricular volumes. You can see decreased ejection. OK. You could just see non-specific things like tachycardia. You could see things like not responsive, not being responsive to pulmonary vasodilators. So there may be something else going on, uh, right. systolic pressure. There's so many different things that you can collect in data points and everybody does it differently. Vic, I can tell, I can feel your passion for CDH from just your explanation of this article. I wanna kick it over to Todd and say, and just ask, I mean, how is, uh, fetal, I'm sorry, neonatal echocardiogram playing a role in management for CDH from your standpoint? I mean, are these catching your eye when you're doing this? So, so, yeah, they're becoming more and more uh discussed when we're evaluating these patients, but, you know, I agree, I can tell that Vic loves this stuff. The problem is that Todd is very specific about the articles he likes. It has to be something that is gonna change his clinical practice. This one balances that. I, or, or this one at least comes close to that, but I can't quite tell. I think it's interesting. I can't tell if left ventricular dysfunction is a marker or an actual cause of higher mortality. Um, so I don't know how it's supposed to play into my practice. Does this mean, and you alluded to this, does this mean I lean more towards repairing on ECMO. Does this mean to early on ECMO, early off ECMO? How, how does this affect my decision tree of going on ECMO, when to go on ECMO, or is this just for counseling the, the families? Um, so, I, I, I need to know that. Vic, what have you, what do you think and what have you seen? So, I think the one thing is that this emphasizes, and maybe this doesn't change, uh, change practice for a lot of folks, is the early echoes. Early, you know, 1st 48 hours of life echo, make that, make that a priority. Uh, I do think that once you have an idea of what the heart is doing, Um, if there is ventricular dysfunction, knowing that ventricular dysfunction profiles can change over time, I think that also says we should get a preoperative echo and a postoperative echo, so we can track this over time. I do think this article supports and encourages institutions to do that. I do think it's important for counseling families and saying, hey, uh, your child does not have a congenital heart anomaly, but there is, the heart is not working as well as it needs to. Uh, there could be a subset of infants with CDH that they don't have bad defect sizes, but they're still sick. And what could it be? It could be their heart. I think it's a great point. And, and the other thing I want to point out is The value of these collaborative studies. Um, uh, the, these are the things we're starting to see more and more of these. And the, the second thing is, what journal was this published in again? This is American Journal of Respiratory and Critical Care Medicine. So, I don't know how many pediatric surgeons subscribe to this journal, but my guess is most don't, which means most will never see this article. And so, this points out, uh, the problem of how we get information now. And that's why I'm glad you brought this to our attention in forums like this, because otherwise, uh, we're gonna miss these articles. So, because a lot of the best articles get published in non-pediatric surgery journals. So for the next article, which is Joe's article, scroll down again, look at the link. There it is. Click on it. Read along with us. So, for this episode, I chose to highlight an article uh by senior authors, Doctor Garcia and Doctor Brown out of Cincinnati Children's entitled, Standardization of Clinical Care Pathway Leads to Sustained decreased length of Stay Following NU pectus repair, a multi-disciplinary quality improvement initiative. So, for this study, uh, the authors, along with their ortho colleagues, created a standardized, uh, post-operative protocol for patients undergoing a NSR, uh, procedure for pectus deformity. So they employed tactics like scheduling anti-emetics, uh, good pain control, using epidurals, but discontinuing them early, actually post-op day 2. Removing Foley's early and encouraging ambulation. Sounds pretty good, but what were the outcome measures? Were activity, lung recruitment, pain control, and then ins and outs. Awesome. So what did they find? So, it showed that this protocol decreased length of stay following enough spa repair from 4.4 days to 3.4 days. So that's huge. It also showed that there were zero readmissions out of 164 patients, and it just doesn't get better than that. Uh, high patient satisfaction scores and high, uh, I'm sorry, low pain scores on telephone follow-up, uh, were also highlighted in their results too. When we asked Joe why this particular article is important, he had a grin cheek to cheek, and this is what he said. So, first things first, um, who doesn't love checklists, right? So the first thing I do every day as a surgical intern is create a checklist of each action item that I have to do that day. I told you he's organized. Uh, they keep you on track, they measure progress as you go, and you know who else loves checklists? Kids and their parents. I think it's a great way, uh, just to sort of track progress and keep everybody on the same page. So, I think the second cool thing about this article is that it really emphasizes multidisciplinary management. They devised this, uh, sort of protocol with lots of stakeholders in mind. So they talked with, you know, not only the pediatric surgery group, but also the anesthesiologists who are administering this pain control. The nurse Educators who are working with the patients and their families, the advanced practice providers who are sort of in the trenches dealing with the patients as well. Physical therapy, occupational therapy, respiratory therapy, and then, of course, the QI folks who are sort of navigating uh the whole process of uh studying this as they go. So, kind of like what Vic was saying, load the boat with a multidisciplinary team. It can only benefit the patient. Probably the most important member of this multidisciplinary care team is the patients and the families. So this group also talked about, uh, the educational program that they had for them. Uh, one interesting aspect of this article kind of caught my eye. They actually did not use any cryotherapy, uh, for pain control on any patients. Uh, so, at University of Wisconsin, they did use cryotherapy, and at Buffalo, they do not. Uh, so I just wanted to kind of read the room on that. Doctor Ponsky, Vic, and Rod. What have you guys seen in terms of cryotherapy? Uh, that caught my eye for sure. Cryo is gaining a lot of traction. Uh, every time I've seen a pectus done, uh, the faculty that I've been with her, uh, very pro cryo, and I've been using it, and studying it. Uh, I think it works. Um, and the article did, the article did make one comment about their thoughts on cryo. So, they did end up saying, you know, we acknowledge that there are studies showing that cryo versus epidurals, uh, showed no difference in pain control, but there's a decreased length of stay with the cryotherapy. But the authors expressed reservations. It sounded like, uh, they mentioned that there was no significant like long-term outcomes data. Um, and that's sort of why they held back from using cryotherapy in this study. I think that's a good point. I, uh, there's no doubt that cryo is getting a lot of visibility. Kansas Kansas City has published quite a bit about it and have shown good results. I, I, I just, you know, I think there is no doubt that we are learning. The more you start protocolizing, your, your outcomes will start improving. And here's just another example of that. And, and as you alluded to, Joe, this is critically important in something like pectus repair, which is so, uh, multidisciplinary. There are so many people involved in the care of these patients. There are so many things to pay attention to. There's pain control, there's rehab, there's These things can be forgotten if you don't have a good systematic protocol. So, I agree with what you said. I think it is a good study. Uh, what I like about this study is it's reproducible because they produce the actual charts of exactly how you do this. So, Day one you could start doing this. Now, I thought you guys did a great job. These are, these are a great, uh, very diverse articles that are, are very timely and, uh, really good. So I appreciate you taking the time to present these. Hopefully you'll do more with us. So what do you guys think? If you're listening to this in the app. You can leave a comment below. Do you do things the same way as Vic and Joe talked about or something different? Have you read these articles and you got an opinion about it? Are you a resident somewhere out in the country who's listening to this saying, hey, I got an article that I want to talk about. Well, reach out to us. We're looking to do many more of these journal clubs for you in the future. Looking to spread awareness about new upcoming, potentially practice changing journal articles, right here on the podcast for you. So, I'm Rod from Cincinnati Children's, and remember, knowledge should be free.