Online Clinical Investigations

Predicting and Surviving Prolonged Critical Illness After Congenital Heart Surgery

DeWitt, Aaron G. MD¹; Rossano, Joseph W. MD²; Bailly, David K. DO³; Bhat, Priya N. MD⁴; Chanani, Nikhil K. MD⁵; Kirkland, Brandon W. MD³; Moga, Michael-Alice MD⁶; Owens, Gabe E. MD, PhD⁷; Retzloff, Lauren B. MPH⁷; Zhang, Wenying MS⁸; Banerjee, Mousumi PhD^8,9; Costarino, Andrew T. MD¹; Bird, Geoffrey L. MD¹; Gaies, Michael MD, MPH, MSc⁷

Author Information

¹Division of Cardiac Critical Care Medicine, Departments of Pediatrics and Anesthesia & Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, PA.

²Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, PA.

³Division of Critical Care, Department of Pediatrics, Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, UT.

⁴Division of Pediatric Critical Care, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX.

⁵Division of Cardiology, Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA.

⁶Department of Critical Care Medicine and Department of Paediatrics, The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, ON, Canada.

⁷Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children’s Hospital, University of Michigan Medical School, Ann Arbor, MI.

⁸Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI.

⁹Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by the University of Michigan Congenital Heart Center, Champs for Mott, and the Michigan Institute for Clinical and Health Research (National Institutes of Health/NCATS UL1TR002240).

Dr. DeWitt disclosed that this study was supported, in part, by funding from the University of Michigan Congenital Heart Center, Champs for Mott, and the Michigan Institute for Clinical & Health Research (National Institutes of Health [NIH]/National Center for Advancing Translational Sciences UL1TR002240). Dr. Rossano received funding from Amgen, Bayer, CSL Behring, and Abbott. Dr. Moga’s institution received funding from the Canadian Institutes of Health Research. Dr. Owens is a consultant for HistoSonics. Dr. Gaies’ institution received funding from the NIH), and he was supported, in part, by funding from the NIH/National Heart, Lung, and Blood Institute (K08HL116639) The remaining authors have disclosed that they do not have any potential conflicts of interest.

This work was performed at the Pediatric Cardiac Critical Care Consortium Data Coordinating Center within the Michigan Congenital Heart Outcomes Research and Discovery Program at the University of Michigan.

For information regarding this article, E-mail: [email protected]

Critical Care Medicine 48(7):p e557-e564, July 2020. | DOI: 10.1097/CCM.0000000000004354

Abstract

Objectives:

Prolonged critical illness after congenital heart surgery disproportionately harms patients and the healthcare system, yet much remains unknown. We aimed to define prolonged critical illness, delineate between nonmodifiable and potentially preventable predictors of prolonged critical illness and prolonged critical illness mortality, and understand the interhospital variation in prolonged critical illness.

Design:

Observational analysis.

Setting:

Pediatric Cardiac Critical Care Consortium clinical registry.

Patients:

All patients, stratified into neonates (≤28 d) and nonneonates (29 d to 18 yr), admitted to the pediatric cardiac ICU after congenital heart surgery at Pediatric Cardiac Critical Care Consortium hospitals.

Interventions:

None.

Measurements and Main Results:

There were 2,419 neonates and 10,687 nonneonates from 22 hospitals. The prolonged critical illness cutoff (90th percentile length of stay) was greater than or equal to 35 and greater than or equal to 10 days for neonates and nonneonates, respectively. Cardiac ICU prolonged critical illness mortality was 24% in neonates and 8% in nonneonates (vs 5% and 0.4%, respectively, in nonprolonged critical illness patients). Multivariable logistic regression identified 10 neonatal and 19 nonneonatal prolonged critical illness predictors within strata and eight predictors of mortality. Only mechanical ventilation days and acute renal failure requiring renal replacement therapy predicted prolonged critical illness and prolonged critical illness mortality in both strata. Approximately 40% of the prolonged critical illness predictors were nonmodifiable (preoperative/patient and operative factors), whereas only one of eight prolonged critical illness mortality predictors was nonmodifiable. The remainders were potentially preventable (postoperative critical care delivery variables and complications). Case-mix–adjusted prolonged critical illness rates were compared across hospitals; six hospitals each had lower- and higher-than-expected prolonged critical illness frequency.

Conclusions:

Although many prolonged critical illness predictors are nonmodifiable, we identified several predictors to target for improvement. Furthermore, we observed that complications and prolonged critical care therapy drive prolonged critical illness mortality. Wide variation of prolonged critical illness frequency suggests that identifying practices at hospitals with lower-than-expected prolonged critical illness could lead to broader quality improvement initiatives.