Cardiac critical care: what really makes a difference.

PURPOSE OF REVIEW: The sustained decline in mortality following congenital heart surgery, while important, also has resulted in an emerging focus upon the use of processes and technological developments to reduce early postoperative morbidity. We summarize here recent efforts within the field of pediatric cardiac intensive care to optimize outcomes associated with the perioperative management of the child with congenital heart disease.

RECENT FINDINGS: Goal-directed and protocol-driven therapy targeting optimization of oxygen delivery improves outcomes in the management of many populations of critically ill patients, and is now increasingly used following congenital heart surgery with a low associated incidence of organ failure and favorable early survival. Restrictive blood product transfusion practices following congenital heart surgery are showing promise in reducing donor exposures and transfusion-associated morbidities without a resulting increase in end organ dysfunction. Technological developments are affording noninvasive opportunities for earlier recognition and intervention in the deteriorating child, while also providing means for support of the failing myocardium, both in an acute setting during cardiopulmonary resuscitation, and among patients with end-stage heart failure requiring longer-term mechanical circulatory support.

SUMMARY: Multi-institutional, prospective evaluation of perioperative management practices, along with patient-specific, integrated electronic health information, provides unique opportunities for investigators to identify and test both processes and technological tools in confronting the most challenging aspects of early postoperative management following congenital heart surgery.