CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 1, January/February 2013
AFRICA
11
Introduction:
Levosimendan is a relatively new calcium-sensitising
drug that opens adenosine triphosphate-dependent potassium (K
ATP
)
channels with effects that increase myocardial contraction and cause
vasodilatation. Its main potential advantages are the improvement
of myocardial contractility without increasing oxygen requirements,
reduction of ventricular preload, and an anti-stunning, anti-ischaemic
effect by opening K
ATP
channels. We present here a large group of
paediatric patients treated with levosimendan.
Methods:
This was a retrospective observational study in our paedi-
atric intensive care unit, in which more than 80 patients received
levosimendan. There were no adverse events attributable to levosi-
mendan and no instances where the clinical condition worsened after
administration. Arterial lactate levels decreased significantly follow-
ing levosimendan administration during cardiopulmonary bypass for
anticipated low cardiac output. In those with established low cardiac
output, trends toward improved haemodynamics were seen, with
heart rate reduction, an increase in mean blood pressure, a reduction
in arterial lactate, and reduced conventional inotrope use.
Results:
Levosimendan was safely and successfully used in a signifi-
cant number of paediatric patients with established low-cardiac output
state who demonstrated improved haemodynamics and tissue perfu-
sion, with a tendency to reduced conventional inotrope usage. This
warrants its evaluation as an inotrope in the paediatric population.
Conclusion:
Levosimendan is the safe drug of choice that could
revolutionise the outcome of cardiac surgery in children.
152: CASE REPORT: CARDIOGENIC SHOCK IN A POST-
OPERATIVE NEONATE WITH CYANOTIC CONGENITAL
HEART DISEASE
Lerusha Naidoo, HR Mackanjee
Inkosi Albert Luthuli Central Hospital, Nelson R Mandela School of
Medicine, South Africa
Cardiogenic shock in a post-operative neonate with cyanotic congen-
ital heart disease is a challenging emergency where the cause deter-
mines management. Postoperatively, iatrogenic complications can be
overlooked, especially when invasive monitoring and haemodynam-
ics become the focus of on-going assessment. We present a male
neonate of 34 weeks’ gestation with pulmonary atresia and ventricu-
lar septal defect who received a right modified Blalock-Taussig shunt
on day 3 of life.
Results:
Postoperatively he remained ventilator-dependent secondary
to nosocomial pneumonia. On day 5 postoperatively he had increasing
ventilatory requirements, with an acute deterioration due to cardio-
genic shock, requiring aggressive resuscitation. Chest X-ray revealed
progressive cardiomegaly. Urgent echocardiography confirmed the
presence of a large pericardial effusion. Pericardiocentesis yielded
80 ml of lipid-rich fluid, with immediate clinical improvement. An
echogenic focus close to the umbilical venous catheter (UVC) tip
was also imaged near the Eustachian valve of the right atrium (RA).
Conclusion:
We present a neonate with cyanotic congenital heart
disease, post-surgery who presented with cardiac tamponade due to a
pericardial effusion. This was a result of infusion from the UVC tip,
which although appropriately positioned, had eroded into the peri-
cardial cavity through the right atrium. The echogenic focus noted on
echocardiography marked the site of erosion. Cardiac tamponade in a
neonate post cardiac surgery can occur unrelated to the operative proce-
dure and its complications. A UVC tip, although appropriately posi-
tioned, had perforated through the RA into the pericardial cavity and
was the unexpected cause of death in this patient. Catheter iatrogenicity
is an important cause of morbidity in postoperative cardiac neonates.
154: MONITORING OF OUTCOME AND PERFORMANCE
IN CONGENITAL HEART SURGERY: COMPLETE AND
VERIFIED SINGLE-INSTITUTION DATA, 16 YEARS OF
PRACTICE
Andrzej Kansy, Andrzej Pastuszko, Malgorzata Mirkowicz-Malek,
Przemyså aw Maruszewski, Bohdan Maruszewski
Department of Cardiothoracic Surgery, Children’s Memorial Health
Institute, Poland
Background
: Analysis of surgical outcomes using raw mortality rate
without risk adjustment is inadequate. The Aristotle basic score and
EACTS-STS mortality score and categories have been developed
based initially on experts’ opinion, and finally on huge amounts of
multi-continental data. These tools allow for monitoring of team
performance over long time periods with regard to increase of
complexity and risk of procedures.
Methods
: Complete and verified data on 8 404 procedures performed
between 1995 and 2010 in our institution were collected in our regis-
try using International Nomenclature for Pediatric and Congenital
Heart Surgery, and EACTS-STS database format; 6 992 procedures
scored by Aristotle basic score and EACTS-STS mortality score and
categories were included. Procedures with less than 25 occurrences
were excluded. Hospital mortality, Aristotle basic score, mortality
score and categories, and postoperative length of stay were used for
measurement of team performance, defined as score × survival/100
and LOS coefficient [100 – LOS (days)/score]. The same calcula-
tions were performed using 8 STS benchmark procedures.
Results
: Mean annual volume of procedures included in the analysis
was 437 (388–510). Mean hospital mortality was 4.55% (3.08–6.81),
mean Aristotle basic score was 5.89 (5.60–6.67), mortality score was
0.59 (0.49–0.79), mortality categories were 1.94 (1.76–2.25), and
mean postoperative LOS was 14.4 days (10.2–25.2). Over 16 years,
continuous increase in team performance followed the increasing
complexity of procedures. Mortality score appeared the strongest
predictor of death in logistic regression analysis [AUC 0.780 (0.77–
0.789)] and was used for calculation of performance and LOS coeffi-
cient. Team performance increased from 0.47 in 1995 to 0.75 in 2010
(
p
<
0.001). LOS coefficient increased from 75.3 to 81.3 (
p
=
0.85).
Conclusions
: Available quality measures allow for continuous
assessment of the team performance in congenital heart surgery.
Increasing complexity and risk of procedures is neutralised by accu-
mulated growth of team experience, represented as team performance
and LOS coefficient.
168: BUG BUSTERS: THEMED INITIATIVE FOR THE
REDUCTION OF INFECTION RATES IN A CARDIAC
INTENSIVE CARE UNIT
Lena Lousa, Harriet McCauley
Great Ormond Street Hospital, London, UK
Background:
To reduce infection rates by raising awareness of
infection risks and types, precautions, preventative measures and
treatment options.
Methods:
Through SWOT analysis we identified strengths, weak-
ness, threats to infection prevention and opportunities for reduc-
ing infections in a cardiac intensive care unit (CICU). To promote
infection awareness we created a ‘BUG BUSTERS’ themed acro-
nym to prompt best practices (Bundles, Utility bins, Gadgets,
Biopatches, Utilising housekeepers, Sterilising, Transformation
website, Educating colleagues, Reducing errors, Stamping out infec-
tions), and recruited key staff to become BUG BUSTER champions.
Staff and parent notice boards were updated, and hand hygiene,
CVL and SSI compliance were audited monthly. CVL route-cause
analysis highlighted femoral lines as a problem area. A new policy
was implemented, introducing biopatches (antimicrobial dressing)
to prevent catheter-related blood stream infections. We organised a
study day and created bay leader checklists to disseminate best prac-
tices throughout the CICU, and created a BUG BUSTERS newsletter
detailing audit results and reiterating ward policies and protocols.
Infection-control teaching for new and existing staff in collaboration
with educational facilitators highlighted inadequate understanding of
infection types. In response we developed a BUG BUSTERS poster
displaying viruses vs bacteria, including routes of transmission,
isolation precautions, preventative and treatment methods.
Results:
Hand hygiene compliance has improved from 93 to 100%
