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Multicenter Validation of the Vasoactive-Ventilation-Renal Score as a Predictor of Prolonged Mechanical Ventilation After Neonatal Cardiac Surgery*

Cashen, Katherine, DO1; Costello, John M., MD, MPH2; Grimaldi, Lisa M., MD3; Narayana Gowda, Keshava Murty, MD4; Moser, Elizabeth A. S., MS5; Piggott, Kurt D., MD6; Wilhelm, Michael, MD7; Mastropietro, Christopher W., MD8

doi: 10.1097/PCC.0000000000001694
Cardiac Intensive Care

Objectives: We sought to validate the Vasoactive-Ventilation-Renal score, a novel disease severity index, as a predictor of outcome in a multicenter cohort of neonates who underwent cardiac surgery.

Design: Retrospective chart review.

Setting: Seven tertiary-care referral centers.

Patients: Neonates defined as age less than or equal to 30 days at the time of cardiac surgery.

Interventions: Ventilation index, Vasoactive-Inotrope Score, serum lactate, and Vasoactive-Ventilation-Renal score were recorded for three postoperative time points: ICU admission, 6 hours, and 12 hours. Peak values, defined as the highest of the three measurements, were also noted. Vasoactive-Ventilation-Renal was calculated as follows: ventilation index + Vasoactive-Inotrope Score + Δ creatinine (change in creatinine from baseline × 10). Primary outcome was prolonged duration of mechanical ventilation, defined as greater than 96 hours. Receiver operative characteristic curves were generated, and abilities of variables to correctly classify prolonged duration of mechanical ventilation were compared using area under the curve values. Multivariable logistic regression modeling was also performed.

Measurements and Main Results: We reviewed 275 neonates. Median age at surgery was 7 days (25th–75th percentile, 5–12 d), 86 (31%) had single ventricle anatomy, and 183 (67%) were classified as Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Category 4 or 5. Prolonged duration of mechanical ventilation occurred in 89 patients (32%). At each postoperative time point, the area under the curve for prolonged duration of mechanical ventilation was significantly greater for the Vasoactive-Ventilation-Renal score as compared to the ventilation index, Vasoactive-Inotrope Score, and serum lactate, with an area under the curve for peak Vasoactive-Ventilation-Renal score of 0.82 (95% CI, 0.77–0.88). On multivariable analysis, peak Vasoactive-Ventilation-Renal score was independently associated with prolonged duration of mechanical ventilation, odds ratio (per 1 unit increase): 1.08 (95% CI, 1.04–1.12).

Conclusions: In this multicenter cohort of neonates who underwent cardiac surgery, the Vasoactive-Ventilation-Renal score was a reliable predictor of postoperative outcome and outperformed more traditional measures of disease complexity and severity.

1Division of Critical Care, Department of Pediatrics, Children’s Hospital of Michigan, Wayne State University, Detroit, MI.

2Division of Cardiology and Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.

3Division of Cardiovascular Intensive Care, Phoenix Children’s Hospital, Department of Child Health, University of Arizona, College of Medicine, Phoenix, AZ.

4Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cleveland Clinic, Cleveland, OH.

5Department of Biostatistics, Indiana University School of Medicine & Richard M. Fairbanks School of Public Health, Indianapolis, IN.

6The Heart Center at Arnold Palmer Hospital for Children, Division of Pediatric Cardiac Intensive Care, Department of Pediatrics, University of Central Florida College of Medicine, Orlando, FL.

7Division of Pediatric Cardiac Intensive Care, Department of Pediatrics, University of Wisconsin, Madison, WI.

8Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN.

*See also p. 1083.

Ms. Moser’s institution received funding from Riley Children’s Hospital’s Pediatric Critical Care Department in exchange for her biostatistical services to support their research. Dr. Mastropietro has received funding from Baez Law Firm for expert witness consultation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Katherine Cashen, DO, Division of Critical Care, Department of Pediatrics, Medicine Children’s Hospital of Michigan, 3901 Beaubien, Detroit, MI 48201. E-mail:

©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies