This document discusses the current setting and organization of paediatric cardiac intensive care units (PCICUs) in 2010. It finds that over recent decades, specialized PCICUs have emerged as central for managing critically ill pediatric and adult patients with congenital and acquired heart disease. The majority of high-volume centers have dedicated PCICUs, while smaller programs care for these patients in mixed pediatric or adult ICUs. An optimal PCICU program involves multidisciplinary collaboration, a risk-stratification strategy, personalized patient care, and specialized nursing staff. Countries in the EU do not have common legislation regarding pediatric ICU organization, but in France programs must perform at least 150 major pediatric cardiac surgeries annually and provide a specialized pediatric ICU.

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. 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. 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. 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. 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.
Conflict of interest statement
None.
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