UTI Cardio Pediátrica: Organização


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UTI Cardio Pediátrica: Organização

  1. 1. Archives of Cardiovascular Disease (2010) 103, 546—551 REVIEW Paediatric cardiac intensive care unit: Current setting and organization in 2010 Réanimation cardiaque pédiatrique : statuts et organisation en 2010 Alain Fraissea,∗ , Stéphane Le Belb , Bertrand Masb , Duncan Macraec a Cardiologie pédiatrique, hôpital d’enfants de la Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France b Département d’anesthésie-réanimation, hôpital d’enfants de la Timone, 13385 Marseille cedex 5, France c Paediatric Cardiac Intensive Care Unit, Royal Brompton Hospital, London, UK Received 5 March 2010; received in revised form 17 May 2010; accepted 18 May 2010 Available online 26 August 2010 KEYWORDS Paediatric cardiology; Intensive care unit; Congenital heart surgery Summary Over recent decades, specialized paediatric cardiac intensive care has emerged as a central component in the management of critically ill, neonatal, paediatric and adult patients with congenital and acquired heart disease. The majority of high-volume centres (dealing with over 300 surgical cases per year) have dedicated paediatric cardiac intensive care units, with the smallest programmes more likely to care for paediatric cardiac patients in mixed paedi- atric or adult intensive care units. Specialized nursing staff are also a crucial presence at the patient’s bedside for quality of care. A paediatric cardiac intensive care programme should have patients (preoperative and postoperative) grouped together geographically, and should provide proximity to the operating theatre, catheterization laboratory and radiology department, as well as to the regular ward. Age-appropriate medical equipment must be provided. An optimal strategy for running a paediatric cardiac intensive care programme should include: multidisci- plinary collaboration and involvement with paediatric cardiology, anaesthesia, cardiac surgery and many other subspecialties; a risk-stratification strategy for quantifying perioperative risk; a personalized patient approach; and anticipatory care. Finally, progressive withdrawal from heavy paediatric cardiac intensive care management should be institutionalized. Although the countries of the European Union do not share any common legislation on the structure and organization of paediatric intensive care or paediatric cardiac intensive care, any paediatric Abbreviations: ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit; PCIC, paediatric cardiac intensive care; PCICU, paediatric cardiac intensive care unit; PICU, paediatric intensive care unit. ∗ Corresponding author. Fax: +33 4 91 38 56 38. E-mail address: alain.fraisse@ap-hm.fr (A. Fraisse). 1875-2136/$ — see front matter © 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.acvd.2010.05.004
  2. 2. Paediatric cardiac intensive care unit 547 cardiac surgery programme in France that is agreed by the French Health Ministry must perform at least ‘150 major procedures per year in children’ and must provide a ‘specialized paediatric intensive care unit’. © 2010 Elsevier Masson SAS. All rights reserved. MOTS CLÉS Cardiologie pédiatrique ; Réanimation ; Chirurgie de la cardiopathie congénitale Résumé Depuis quelques années, la spécialité de réanimation cardiaque pédiatrique est dev- enue indispensable à la réanimation des patients atteints de cardiopathie congénitale, de la période néonatale à l’âge adulte. Concernant les ressources humaines, la majorité des centres à volume important (> 300 chirurgies par an) ont des unités de réanimation dédiées à la cardiologie pédiatrique, alors que les centres moins importants ont en général des unités de réanimation polyvalente pédiatrique ou même adulte dans lesquelles sont hospitalisés les patients car- diaques congénitaux. Une équipe paramédicale spécialisée est également indispensable pour la qualité des soins. Idéalement, la prise en charge en réanimation cardiaque pédiatrique des patients chirurgicaux doit les regrouper sur le même site durant la période pré- et postopéra- toire. La réanimation doit être à proximité du bloc opératoire de la salle de cathétérisme, du service de radiologie et également de l’unité d’hospitalisation conventionnelle spécialisée. Des équipements spécifiques, adaptés à l’âge doivent y être disponibles. Le fonctionnement optimal d’un programme de réanimation cardiaque pédiatrique nécessite une collaboration multidisci- plinaire, en particulier avec la cardiologie pédiatrique, l’anesthésie pédiatrique, la chirurgie cardiaque et beaucoup d’autres sur-spécialités. Une stratification du risque périopératoire et une approche personnalisée du patient doivent être développée, de même qu’une stratégie d’anticipation des soins de réanimation. Enfin, le transfert des patients de la réanimation car- diaque pédiatrique à un service de surveillance continue ou d’hospitalisation conventionnelle doit être institutionnalisé. Sur le plan administratif et législatif, les pays de l’Union européenne n’ont pas de législation commune sur l’organisation structurelle et fonctionnelle des unités de réanimation pédiatrique polyvalente ou cardiaque. En France, tout programme de chirurgie cardiaque pédiatrique agréé par le ministère de la Santé doit comprendre au moins 150 inter- ventions majeures par an chez l’enfant et doit également disposer d’une unité de réanimation spécialisée. © 2010 Elsevier Masson SAS. Tous droits réservés. Introduction Over recent decades, specialized paediatric cardiac inten- sive care (PCIC) has emerged as a central component in the management of critically ill, neonatal, paediatric and adult patients with congenital and acquired heart disease. Despite the large numbers of paediatric cardiac centres worldwide, few papers have been published that describe adequately the components that make up a dedicated cardiac intensive care service [1—3]. The concept of a PCIC unit (PCICU) varies widely, ranging from units that are largely managed surgi- cally, to those in which children with heart disease are cared for in a general intensive care environment [4]. We review here different elements that seem to us to be important in the establishment of a PCICU, based on clinical experience within a contemporary legal and administrative framework. Organization and equipment Human resources Medical personnel Paediatric intensivists lead 94% of general paediatric inten- sive care units (PICUs) [5]. With regard to PCICUs, a recent survey of both North American and worldwide paediatric cardiac surgical programmes showed that 73% of North American units and 59% of worldwide units involved care by paediatric intensivists. All but two of 29 high-volume centres (dealing with > 300 surgical cases/year) cared for paediatric cardiac intensive care patients in dedicated PCICUs, with the smallest programmes more likely to care for these chil- dren in mixed paediatric or adult intensive care units (ICUs) [6]. Paediatric cardiac intensivists usually train in either paediatric medicine or anaesthesia as a ‘base specialty’, with further specialist training in paediatric intensive care and paediatric cardiac intensive care or cardiology. While they clearly must have expertise in the management of congenital and acquired heart disease in children, these intensivists also require expertise in the management of non-cardiac organ failure and the interaction of whole body systems. Experience from high-performance programmes shows that intensive care for children with heart disease is best delivered by a well-structured, multidisciplinary, medical team comprising critical care medicine, paediatric cardi- ology, cardiac surgery and cardiac anaesthesia, supported by specialized paediatric cardiac trained nurses and oth- ers, including paediatric pharmacists, physiotherapists and support staff for families [3]. Additional medical specialists that are involved closely include neonatologists, paediatric general surgeons, paediatric pulmonologists and paediatric
  3. 3. 548 A. Fraisse et al. neurologists. Recent studies have demonstrated that multi- disciplinary rounds in the critical care environment increase communication, reduce medical errors, shorten hospital stay and consequently produce economic savings [7,8]. In-house, 24-hour, attending-level coverage is recom- mended for any general PICU as well as for PCICUs [3,9], although this ideal is rarely achieved and may not be afford- able in many health economies. While institutions with training programmes often have residents or fellows to pro- vide night and weekend call coverage, other institutions will need coverage to be provided by physician extenders and/or attending staff. It is certainly questionable whether stan- dards of care can remain at the highest level, when junior, inexperienced staff alone assess and treat children ‘out of hours’. Education of all members of the team is a vital part of a PCIC programme. Orientation of trainees and nurses should be included on a systematic basis. Specific knowledge areas, such as single ventricle pathophysiology, pulmonary hyper- tension and low cardiac output management, mechanical support usage and the diagnosis and treatment of complex tachydysrhythmias should be reviewed on a periodic basis. Finally, both trainee and nursing staff should be encouraged to train together as a team. Recent development of medical simulation training has enabled advanced team training and safety to be taught in ways originally developed in aviation and other ‘high resilience’ industries. Nurses and other ancillary personnel Nurses provide a unique contribution to the delivery of care for PCICU patients. Specialized nursing staff are a cru- cial presence at the patient’s bedside for quality of care, and have a strong influence on the rate of preventable adverse events [3]. A study conducted recently in an ICU demonstrated that 51% of incidents are detected by direct observation versus 27% by monitors [10]. The patient-to- nurse ratio can range from 1:3 to 2:1 in PICUs [11]. In some European countries, such as the UK, 1:1 nursing is regarded as standard for a ventilated adult or child, with a higher 2:1 ratio for complex care, including extracorporeal membrane oxygenation (ECMO). Other health systems have adopted dif- ferent standards, and there is little high-quality research to support the ‘rules’ applied to PICU nursing ratios. Other factors should be considered, including the level of expe- rience, available technology and monitoring, and support staff. For instance, a highly experienced nurse may be capa- ble of directing the care of several patients located in close proximity, provided they have support staff nearby and more experienced staff to call upon should an emergency arise. The nursing staff in PCICUs should be encouraged to attain some degree of clinical autonomy. Many pro- grammes have developed ‘practitioners’ who have extended their professional practice variously into areas regarded traditionally as ‘medical’. It is essential that whoever leads the care ensures open and clear communication with all members of the care team. Recently introduced communication tools adopted from other industries, such as Situation-Background-Assessment-Recommendation [12], can be adopted across whole units or hospitals and have been shown to result in better communication of critical informa- tion, especially when the information is passed from junior to senior team members or in stressful situations. It is often productive for cardiac intensive care nurses to rotate peri- odically through other areas of the cardiac programme, such as the catheterization laboratory or the operating theatre, to gain more extensive knowledge of these clinical areas. In addition, rotations through general PICUs and transport programmes can be beneficial. Regular meetings between physicians and nursing staff should be organized on a weekly basis to discuss both clinical and administrative aspects of unit work. Numerous other personnel are mandatory for the optimal care of the PCICU patient. A dedicated pharmacist should be close to the PCICU, or an organization must at least be available to allow 24-hour dispensation of medication. Nutritionists, physical therapists, psychologists and social workers also play important roles in PCICUs. Facility and equipment Issues to consider regarding PCICU location strategy It is preferable to have PCIC patients grouped together geo- graphically, whether in a separate PCICU or in part of a general PICU; this permits specialized nursing and focuses the medical care from the ‘cardiac’ multidisciplinary team [1—3]. Proximity to the operating room, catheterization lab- oratory and radiology department has the obvious advantage of minimizing transport time and enables ready communi- cation between key team members. Having preoperative patients in the same location as postoperative patients facilitates ongoing management, especially when surgery or interventional catheterization has to be scheduled. Finally, proximity to the regular ward is also advantageous. Issues to consider regarding PCICU conception and construction Medical and nursing directors, the hospital architect, the hospital administrator and operating engineer should all be involved at the conception and building phase of a PCICU. The central area should have adequate visualization of the patient rooms as well as adequate desk space. A central- ized monitoring system with telemetry for any ‘mobile’ patients is mandatory. There should be individual rooms that are large enough to accommodate the patient’s bed, echocardiographic machines, mechanical support and vac- uum source. The minimum recommendation for paediatric patients is 23 m2 per bed space [13]. Some units are designed with patients in multibedded bays; while these give patients and families less privacy, they may prove effective and popular with nurses, particularly if nurse ratios are lower than 1:1, permitting mutual support from adjacent nurses at times of crisis. In addition, a movable glass partition door between rooms enables the space around the bed to be doubled in certain emergency situations. Adherence to regulatory standards, including isolation rooms, clean and dirty utility rooms, and nutrition preparation areas, is also important [13,14]. Issues to consider regarding PCICU equipment Age-appropriate medical equipment must be provided, according to previously published guidelines for PICUs
  4. 4. Paediatric cardiac intensive care unit 549 [13,14]. In addition, PCICUs have several specialized equip- ment needs, such as inhaled nitric oxide, mechanical cardiopulmonary support and echocardiographic machines with transesophageal probes [1,2]. This equipment should be inside or in close proximity to the PCICU and able to be readily deployed when needed. In addition, there must be accurate and unbiased recording of data from monitoring equipment, which is retrievable for at least the previous 24 hours. Specific cardiac monitors should automatically record, interpret and immediately commu- nicate any abnormal data (e.g. significant arrhythmias). Electronic patient charting systems allow for semiauto- matic data acquisition and automatic calculation of fluid and drug administration. Many of these systems include e-prescribing for drugs, which, if set up properly, can be a valuable decision-support tool for prescribers and can improve medicine safety. Data can also be collected and be readily available for discharge notes or clinical audit. All PICUs should audit practice against standards, ideally benchmarking externally using severity of illness scores such as the Paediatric Index of Mortality score or the Paediatric Risk of Mortality score, in addition to paediatric cardiac spe- cific ‘complexity’ scores, such as the Risk Adjustment for Congenital Heart Surgery score for surgical interventions. Finally, any referral PCICU should incorporate telemedicine technology to provide interactive consultation and support- ive care to other external units with or without a PICU [15]. Issues to consider regarding PCICU clinical practice Admission and discharge criteria should be discussed with members of the paediatric cardiology and paediatric cardiac surgery teams. Although individualized variations in clini- cal practice are unavoidable — and possibly useful to some extent — they should be minimized. Cardiopulmonary arrest and emergency situations deserve special protocols, particu- larly regarding the intervention of the ECMO team. Protocols for specialized patient populations, from neonates to adults with congenital heart disease, are also useful. A regular car- diac intensive care physician and nursing staff meeting is a very useful forum for discussing and establishing new poli- cies [3]. Also, a weekly morbidity and mortality conference for all admissions and discharges is mandatory to improve quality of care. Other PCICU issues to consider Patient satisfaction is an important aspect of the quality of medical care. Visitation policy for families should be fairly open and support for parents should be readily avail- able from physicians, nurses and a dedicated psychologist. Finally, as with every PICU or adult ICU, the staff physicians should be knowledgeable about cost-to-charge ratios as well as direct and indirect expenses in the intensive care setting [16]. Strategy Several principles are of primary importance if a PCIC pro- gramme is to be run optimally. Multidisciplinary collaboration and involvement In addition to paediatric cardiology, PCIC, anaesthesia and cardiac surgery, a PCICU incorporates many other subspe- cialties, such as neonatology, paediatric pulmonology and adult cardiology [3,7]. Risk stratification In the field of PCIC medicine, it is difficult to estimate risk for individual patients. A global score, such as the Physi- cal Status Classification score of the American Society of Anesthesiology, is not valid because age and underlying diagnoses are not taken into account [17]. For congenital heart surgery, several risk models (e.g. the Risk Adjustment in Congenital Heart Surgery score and the Aristotle score) have been established over the past few years to quantify perioperative risk more specifically. Also, some blood mark- ers (e.g. N-terminal pro-brain natriuretic peptide) may be capable of predicting postoperative morbidity and mortality [18]. Continuation of care As long as the intensive care admission is predictable, PCIC should not start with postoperative or postcatheteriza- tion care. Rather, the patient’s intensive care management should begin with their initial presentation at the clinic, conventional hospitalization or even the initial multidisci- plinary discussion. For example, assessment of preoperative patients includes numerous issues, such as evaluation of myocardial and valve function, pulmonary artery pressure, consideration for preoperative and intraoperative inotropic support, assessment of any extracardiac associated anomaly and potential sequelae after cardiopulmonary bypass [2,3]. Personalized approach The intensivist must consider the extreme variability in patients with CHD [3]. For example, after a modified fenestrated Fontan operation, any patient may use their fenestration variably, with a consecutive wide degree of postoperative cyanosis [19]. The individual approach for such patients needs to consider many clinical factors (rhythm, pulmonary pressure and resistance, systemic pres- sure, etc.), biological factors (lactates, pH, arteriovenous difference, etc.) and echocardiographic factors (ventricu- lar function, valve function, etc.), as well as the patient’s postoperative treatment — particularly optimization for afterload reduction. Anticipatory care Anticipation has become a concept of paramount impor- tance as experience in PCIC medicine has grown and given the rapidity of development of many fatal complications in the critically ill paediatric cardiac patient [3]. A well- known example is the instauration of mechanical support in a patient in whom continuous inotropic support with epinephrine exceeds 0.2 ␮g/kg/min [20].
  5. 5. 550 A. Fraisse et al. Progressive withdrawal from heavy PCIC management Progressive withdrawal from heavy PCIC management should be institutionalized instead of making abrupt changes, especially with inotropic and ventilator management. For example, inhaled nitric oxide withdrawal should be very progressive, even at extremely low doses, to avoid rebound pulmonary hypertension [21]. Centralizing care There are strong arguments in favour of centralizing the care of critically ill paediatric cardiac patients at the inter- regional level. Several key elements play a crucial role in optimizing the interactions between the referral centre and the external centre: the use of common protocols; rou- tine consultation with the inter-regional PCICU; the use of telemedicine; and continuous medical education to enhance the skills and experience of local staff [15,22]. The existence of a dedicated inter-regional paediatric team optimizes patient care during transportation, and a mobile ECMO team delivers care in an urgent and lifesaving manner [23]. Peer review of the programme Both internal and external periodic peer review of the pro- gramme should be institutionalized to optimize performance of the team responsible for PCIC. While an unbiased assess- ment might be better provided by a respected external expert, the use of a standardized scorecard is an effec- tive tool for internal as well as for external reviewers. After quantitative assessment of the PCICU team is accomplished by giving a score to each of the issues (e.g. multidisciplinary collaboration, location strategy, etc.), recommendations and/or interventions are suggested. This is followed later by a comparative reassessment of the improvement in per- formance. A very good example of such scorecard has been published in a recent review on PCICUs [3]. Legal aspects The countries of the European Union do not share any com- mon legislation about the structure and organization of general paediatric intensive care or PCIC. In France, sev- eral decrees have been published by the Health Ministry regarding the practice of paediatric cardiac surgery. Any paediatric cardiac surgery programme must be agreed by the French Health Ministry and programmes must fit closely with the decree issued on 24 January 2006 and modified on 07 March (no 2006-77, no 2006-78) [24] and with the Intermin- isterial Circular issued on 03 July 2006 (no 2006-293) from the Direction hospitalière de l’organisation des soins, regulating cardiac surgery practice in France [25]. To be acknowledged, a paediatric cardiac surgery programme must complete at least ‘150 major procedures per year in children’. Each insti- tution should have a ‘dedicated paediatric cardiology unit, a paediatric catheterization laboratory and a PCICU’. Postop- erative care of the paediatric cardiac patient is provided ‘in a dedicated PCICU or in a general PICU with identi- fied cardiosurgical beds’. Such a specialized unit is defined legally as a ‘specialized PICU’. Managers of such units can be board-certified intensivists or paediatricians who have the appropriate intensive care medicine board certification. Specialized PICUs also benefit from a 2:1 patient-to-nurse ratio instead of the ‘standard’ 5:2 ratio in general PICUs. Protocols on organization and medical care must be estab- lished between the paediatric cardiac surgical department and the PCICU. Conclusion Seriously ill and postoperative cardiac patients are best managed in the ICUs designed for them. A multidisciplinary team of intensivists, paediatric cardiologists, paediatric car- diac surgeons and others is designed to provide optimal care to the critically ill paediatric cardiac patient, using specifi- cally dedicated facilities, equipment and strategies. 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  6. 6. Paediatric cardiac intensive care unit 551 [13] Rosenberg DI, Moss MM. Guidelines and levels of care for pedi- atric intensive care units. Pediatrics 2004;114:1114—25. [14] Guidelines for intensive care unit design. Guidelines/Practice Parameters Committee of the American College of Critical Care Medicine. Society of Critical Care Medicine. Crit Care Med 1995;23:582—8. [15] Austin JD. Critically ill children in non-paediatric intensive care units: a survey, review and proposal for practice. Anaesth Intensive Care 2007;35:961—7. [16] Chalom R, Raphaely RC, Costarino Jr AT. Hospital costs of pediatric intensive care. Crit Care Med 1999;27: 2079—85. [17] Mak PH, Campbell RC, Irwin MG. The ASA Physical Status Classification: inter-observer consistency. American Soci- ety of Anesthesiologists. Anaesth Intensive Care 2002;30: 633—40. [18] Wessel DL, Fraisse A. Preoperative care of the pediatric car- diac surgical patient: general considerations. In: Nichols DG, editor. Rogers’ textbook of pediatric intensive care. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 1149—58. [19] Wessel DL, Fraisse A. Preoperative care of the pediatric cardiac surgical patient: lesion-specific management. In: Nichols DG, editor. Rogers’ textbook of pediatric intensive care. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 1159—80. [20] Reddy M, Hanley FL. Mechanical support of the myocardium. In: Chang AC, Hanley FL, Wernovsky G, et al., editors. Pedi- atric cardiac intensive care. Baltimore: Lippincott Williams & Wilkins; 1998. p. 345—9. [21] Pearl JM, Nelson DP, Raake JL, et al. Inhaled nitric oxide increases endothelin-1 levels: a potential cause of rebound pulmonary hypertension. Crit Care Med 2002;30:89—93. [22] Sable C. Telemedicine applications in pediatric cardiology. Min- erva Pediatr 2003;55:1—13. [23] Tissot C, Buchholz H, Mitchell MB, et al. First pediatric transat- lantic air ambulance transportation on a Berlin Heart EXCOR left ventricular assist device as a bridge to transplantation. Pediatr Crit Care Med 2010;11:e24—5. [24] Legifrance. Décret no 2006-77 du 24 janvier 2006 relatif aux conditions d’implantation applicables aux activ- ités de soins de chirurgie cardiaque et modifiant le code de la santé publique (dispositions réglementaires). http://www.legifrance.gouv.fr/affichTexte.do;jsessionid= EA70D6F66C231E76E14DBE34FADD3ABC.tpdjo13v 3?cidTexte= JORFTEXT000000453947&categorieLien=id. [25] Direction hospitalière de l’organisation des soins. Circu- laire DHOS/O4 no 2006-293 du 3 juillet 2006 relative à l’activité de soins de chirurgie cardiaque. http://www.sante. gouv.fr/adm/dagpb/bo/2006/06-08/a0080017.htm.