Intensive Care of Patients with Pediatric and Congenital Heart Disease
The complexity and scope of patients cared for in the pediatric cardiac intensive care unit (PCICU) has expanded considerably over the last several decades. Technologic and surgical advances have improved survival for infants and children with congenital heart disease (CHD), and infants with increasingly complex anatomy and multiple comorbidities receive surgical interventions. Improved short-term survival has also translated into an increased number of adult patients living with CHD, a cohort of patients who present challenges to both pediatric and adult cardiologists. The wide breadth of pathology and complexity in PCICUs requires a dedicated team approach to ensure a seamless transition from the cardiovascular operating suite to the intensive care unit. An approach utilizing input from pediatric cardiac surgeons, pediatric cardiologists, intensivists, cardiac anesthesiologists, adult congenital specialists and other skilled providers is necessary.
Physicians caring for perioperative patients with CHD require a sophisticated understanding of oxygen transport balance and the compensatory circulatory responses to increased oxygen consumption or decreased oxygen delivery. The principal goal is ensuring adequate tissue oxygen delivery and preventing end organ dysfunction. Physicians practicing in PCICUs have a variety of training backgrounds, most commonly a combination of training in the fields of pediatric cardiology and pediatric critical care. Although training pathways are variable, a sophisticated understanding of critical disease in patients with congenital or acquired cardiovascular disease is required to care for the complex patients in the PCICU. This includes, but is not limited to, cardiac anatomy and physiology, pediatric cardiac surgery, cardiopulmonary interactions, respiratory physiology, mechanical ventilation, renal replacement therapy, and neurologic pathology. Detailed knowledge regarding the anatomy and physiologic state of infants and children with CHD allows for preoperative planning and risk stratification, and anticipation of hemodynamic derangements in the postoperative period. When clinical manifestations are not in accordance with the expected physiology, additional investigation should occur promptly. Despite a multitude of monitoring modalities, challenges exist in the collection and visualization of the enormous quantity of patient specific data. As PCICU’s become busier, patients become more complex, and staffing models evolve, we again look to technology to provide a streamlined approach to the evaluation of these patients. The development of predictive analytic models that integrate multiple physiologic, laboratory, and other data to provide early and consistent identification of patients who are suffering from inadequate oxygen transport balance, or are nearing a clinical decompensation, is the next frontier of pediatric cardiac intensive care medicine.
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