Neonatal outcome with congenital heart disease: Experience of Dhaka Shishu Hospital Paediatric Cardiac Intensive Care Unit Dr. Mohammad Abdullah Al Mamun, Prof. Manzoor Hussain, Dr. Rezoana Rima, Dr. Suntanu Kumar Kar, Dr. Abdul Jabbar, Dr. Chandan Saha, Dr. Imam Hasan, Dr. Sazzadul Islam Department of Paediatric Cardiology Dhaka Shishu (Children) Hospital Dhaka Shishu (Children) Hospital
• Like other developing countries, Bangladesh is facing a multitude of health problems. • Pediatric heart disease is one of them. Wren et al. Temporal variability in birth prevalence of cardiovascular malformations. Heart 2000;83:414-19.
Hypothetical estimation of CHD in Bangladesh Live birth: 3,593,326 World Factbook, July 2014 Incidence of CHD: 8/1000 live birth Estimated CHD among LB: 28,746/year Still birth 36/1000, WHO data Incidence of CHD among still birth: 10% (WHO data) Estimated CHD among SB: 12,855/year More then 40,000 CHD in each year in Bangladesh
• Without early recognition, diagnosis and treatment, a majority of infants and children with CHD die in their first month of life in developing countries. Payne et al. Toward a molecular understanding of congenital heart disease. Circulation 1995;91:494-504.
• The care of children with congenital heart disease has progressed in the last 60 years. • Now a days, even complex Congenital Heart Diseases can be treated with the appropriate surgical or catheter intervention. • So timely recognition and referral to cardiac center is crucial for good outcome.
Early diagnosis Rapid stabilization Developments Improvements in in pediatric imaging cardiology Advanced interventional techniques Newer treatment options
Pediatric intensive care grew with • Advances in surgical and medical subspecialties • And development of sophisticated life- support technology.
Other subspecialists Nurse specialists Respiratory therapists Multidisciplinary Intensivist team Nutritionists Social workers Occupational therapists
Adult respiratory intensive care Neonatology and neonatal intensive care John down in Five crucial fields 1992 of medicine Pediatric general surgery Pediatric cardiac surgery Pediatric anesthesiology Hoffman et al. The incidence of congenital heart disease. J Am Coll Cardiol, 2002; 39:1890-1900.
• Over the years hundreds of Paediatric Intensive Care Unit established in academic institution, children hospital and many community hospital worldwide.
• Since the origin of the first dedicated pediatric intensive care units in 1950s, the field of pediatric intensive care has been expanding and sprouting new subspecialties. Richmond S, Wren C. Early diagnosis of congenital heart disease. Semin Neonatal 2001;6:27-35.
• The concept of dedicated pediatric cardiac intensive care unit (PCICU) originated from the unique requirements for management of children after cardiac surgery and cardiac intervention.
• Thus, pediatric cardiac intensive care emerged as a new subspecialty to fulfill the unique needs of childre n with congenital and acquired heart disease. Wren et al. Twenty year trends in diagnosis of life threatening neonatal cardiovascular malformations. Arch Dis Child Fetal Neonatal Ed. 2008; 93:33. • One study evaluated the benefits of a dedicated PCICU and found that establishment of a dedicated PCICU has shown better outcome. Baden et al. Intensivist-led team approach to critical care of children with heart disease. Pediatrics. 2006;117:1854-6.
• The concept of a PCICU varies widely. • The services are provided by a multidisciplinary team that includes pediatric cardiologists, pediatric cardiac surgeons, intensivists, critical care nurses, respiratory therapists, and other support personnel. Kuehl KS, Loffredo CA, Ferencz C. Failure to diagnose congenital heart disease in infancy. Pediatrics 1999;103:743-747.
Pediatric heart programs are often attached to well-established adult cardiology and cardiac surgery programs, and PCICU care is sometimes delivered in a common setting with shared space, infrastructure, and personnel Models of PCICU in developing countries Sometimes it is run by anesthesiologist In small private establishments, it is delivered by a small group of professionals attached to the surgical unit Mahle et al. Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the AHA and AAP. Pediatrics 2009;124:823-836.
Objective • As neonates having acute cardiovascular compromise required more meticulous care this study was conducted to see neonatal outcome with CHD in PCICU.
Methodology • This cross sectional study was conducted in PCICU of Dhaka Shishu (Children) Hospital from February 2012 to July 2015. • Neonatal cardiac surgery is not yet started at Dhaka Shishu (Children) Hospital. • Neonates with CHD admitted during the study period for medical management and neonatal cardiac intervention were included. • Data were collected from hospital records and analyzed by using SPSS version 17.
Results • Total 266 neonates with CHD were admitted during the study period. • Mean age were 9.03±7.26 days.
176, 38.8% Male Female 90, 66.2% Fig: Distribution of sex of neonates in PCICU (n=266) Male were 66.2% and female were 33.8% with a male female ratio 1.96:1.
209, 21.4% Term Preterm 57, 78.6% Fig: Distribution of gestational age of neonates in PCICU (n=266) Among the neonates term were 78.6% and preterm were 21.4%.
46.6 50 45 40 30.1 35 30 Percent 21.1 25 20 15 10 2.3 5 0 Respiratory distress Murmur Cyanosis Heart failure Fig: Distribution of clinical suspicion of CHD in neonate (n=266) A large group of neonate presented with cardiac murmur 124(46.6%), respiratory distress 80(30.12%), cyanosis 56(21.1%) and heart failure 6(3.4%).
190, 28.57% Acyanotic Cyanotic 76, 71.43% Fig: Distribution of CHD among neonates in PCICU (n=266) Majority of Congenital CHD were of Acyanotic CHD (190, 71.43%).
List of acyanotic CHD DISEASE Number (%) ASD 37(13.9%) VSD 49(18.4%) PDA 29(10.9%) ASD with VSD 8(3%) PFO 6(2.3%) VSD with PDA 7(2.63%) ASD with PDA 24(9.02%) ASD with VSD with PDA 4(1.5%) AV canal defect 6(2.3%) Pulmonary stenosis 2(0.8%) CoA 4(1.5%) Others 14(5.26%)
List of cyanotic CHD Number (%) DISEASE Tetralogy of Fallot 11(4.1%) Transposition of great arteries 18(6.8%) Tricuspid Atresia with Shunt 6(2.3%) Pulmonary Atresia with Shunt 13(4.9%) TAPVC with Shunt 10(3.8%) Truncus Arteriosus 5(1.9%) Single Ventricle 3(1.1%) DORV 6(2.3%) Hypoplastic Left Heart Syndrome 4(1.5%)
Cardiac intervention among the neonates during the study period Special interventions Number BAS 12 PDA stenting 8
35, 13.2% 151, 56.7% Discharge DORB 80, Death 30.1% Fig: Distribution of outcome of neonates in PCICU (n=266) Among the admitted patients 151(56.7%) were discharged, 80(30.1%) died, 35(13.2%) leave against medical advice.
Distribution of outcome of Acyanotic CHD (n=163) No Diagnosis Outcome, n(%) Survived Died 25(83.3) 5(16.7%) ASD 30 32(74.4%) 11(25.6%) VSD 43 18(69.2%) 8(30.8%) PDA 26 4(57.1%) 3(42.9%) ASD with VSD 7 4(80%) 1(20%) PFO 5 4(51.1%) 3(42.9%) VSD with PDA 7 18(85.7%) 3(14.3%) ASD with PDA 21 2(66.7%) 1(33.3%) ASD with VSD with PDA 3 1(25%) 3(75%) AV canal defect 4 2(50%) 2(50%) Pulmonary stenosis 4 1(33.3%) 2(66.7%) CoA 3 6(60%) 4(40%) Others 10 117(71.78%) 46(28.22%) Total 163
Distribution of outcome of Cyanotic CHD Diagnosis No Outcome, n(%) Survived Died 7(100%) 0(0%) Tetralogy of Fallot 7 5(33.3%) 10(66.7%) Transposition of great arteries 15 0(0%) 4(100%) Tricuspid Atresia with Shunt 4 10(66.7%) 5(33.3%) Pulmonary Atresia with Shunt 15 2(20%) 8(80%) TAPVC with Shunt 10 0(0%) 4(100%) Truncus Arteriosus 4 0(0%) 3(100%) Single Ventricle 3 6(100%) 0(0%) DORV 6 0(0%) 4(100%) Hypoplastic Left Heart Syndrome 4 30(44.12%) 38(55.88%) Total 68
25 22.9 19.2 19.17 20 18.04 16.54 15 Percent 10.52 10 6 5.63 5 3 2.3 0 Perinatal Pneumonia PTLBW Sepsis Heart Shock Metabolic Renal IDM Others Asphyxia failure Acidosis Failure Fig: Co-morbid conditions among neonates with CHD (Multiple response) Co morbid condition like prematurity, perinatal asphyxia and sepsis also contributed in mortality.
Conclusion • Pediatric cardiac intensive care in developing nations is still in infancy. • As a newly established sector survival of neonates with heart disease admitted for medical care is satisfactory.
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