Stay Current Journal Club: Episode 1 - Ventricular Dysfunction in CDH and...
With Dr. Joe La Hillier & Dr. Todd Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Joe La Hillier is a general surgery intern at the University of Buffalo
Vic is a PGY4 resident from UT Southwestern in Dallas, doing lab work at UT Houston McGovern Medical School studying diaphragmatic hernia
The ventricular dysfunction study is from December 2019 in American Journal of Respiratory and Critical Care Medicine
The first author is Neil Pattel, a neonatologist from Glasgow, and the senior author is Doctor Harding
The study used CDH Study Group data from 2015 to 2018 as a retrospective review of prospectively collected data
The primary outcome was survival to discharge, examining early cardiac dysfunction on echo within the first 48 hours of life
Patients were split into four groups: normal ventricular function, right ventricular dysfunction only, left ventricular dysfunction only, and biventricular dysfunction
39% of CDH patients had some evidence of cardiac dysfunction on their first echogram in the first 48 hours of life
Cardiac dysfunction was an independent predictor of mortality and outcomes
Patients with normal cardiac function had survival over 80%
Patients with right ventricular dysfunction only had survival of 74%
Patients with left ventricular dysfunction had survival of 57%
Patients with biventricular dysfunction had survival of 50%
Even when adjusting for liver position, defect size, and other important variables, cardiac dysfunction was still a significant driver of mortality
The authors push for the importance of evaluating early cardiac function in CDH patients with an early echocardiogram in the first 48 hours of life
The CDH study group does not prescribe standardized management and does not tell institutions how to standardize management
The data collection tool asks if early echo was done, what day, and whether there was cardiac dysfunction (right ventricular dysfunction yes or no, and if yes, was it systolic or diastolic)
Pulmonary hypertension is a predictor of mortality for CDH infants
With pulmonary hypertension you can see decreased right ventricular ejection
Decreased right ventricular ejection can lead to bowing of the septum into the left ventricle
Septal bowing can result in decreased ventricular volumes and decreased ejection
The pectus repair study is entitled 'Standardization of Clinical Care Pathway Leads to Sustained decreased length of Stay Following Nuss pectus repair, a multi-disciplinary quality improvement initiative' by senior authors Doctor Garcia and Doctor Brown from Cincinnati Children's
The authors created a standardized post-operative protocol for patients undergoing Nuss procedure for pectus deformity
The protocol employed tactics like scheduling anti-emetics, good pain control using epidurals but discontinuing them early on post-op day 2, removing Foleys early, and encouraging ambulation
Outcome measures were activity, lung recruitment, pain control, and ins and outs
The protocol decreased length of stay following Nuss pectus repair from 4.4 days to 3.4 days
There were zero readmissions out of 164 patients
The study showed high patient satisfaction scores and low pain scores on telephone follow-up
The protocol emphasized multidisciplinary management with stakeholders including pediatric surgery, anesthesiologists, nurse educators, advanced practice providers, physical therapy, occupational therapy, respiratory therapy, and QI personnel
The Cincinnati group did not use any cryotherapy for pain control on any patients in this study
At University of Wisconsin they use cryotherapy for pectus repair, and at Buffalo they do not
Cryotherapy is gaining traction and faculty using it believe it works
Studies show cryo versus epidurals showed no difference in pain control but decreased length of stay with cryotherapy
The Cincinnati authors expressed reservations about cryotherapy due to lack of significant long-term outcomes data
Kansas City has published quite a bit about cryotherapy and shown good results