- Pediatric Cardiovascular Intensive Care
- Pediatric Cardiology
Clinical Assistant Professor, Pediatrics - Cardiology
Fellowship, Stanford University, Pediatric Cardiovascular Intensive Care (2018)
Board Certification: American Board of Pediatrics, Pediatric Cardiology (2018)
Fellowship, Stanford University, Pediatric Cardiology (2016)
Board Certification: American Board of Pediatrics, Pediatrics (2016)
Residency, University of California at San Francisco, Pediatrics (2011)
MD, University of California at San Francisco, Medical Education (2008)
MS, Stanford University, Biological Sciences (2004)
BAS, Stanford University, Biological Sciences and Psychology (2003)
Acute Cardiac Care for Neonatal Heart Disease.
2022; 150 (Suppl 2)
This manuscript is one component of a larger series of articles produced by the Neonatal Cardiac Care Collaborative that are published in this supplement of Pediatrics. In this review article, we summarize the contemporary physiologic principles, evaluation, and management of acute care issues for neonates with complex congenital heart disease. A multidisciplinary team of authors was created by the Collaborative's Executive Committee. The authors developed a detailed outline of the manuscript, and small teams of authors were assigned to draft specific sections. The authors reviewed the literature, with a focus on original manuscripts published in the last decade, and drafted preliminary content and recommendations. All authors subsequently reviewed and edited the entire manuscript until a consensus was achieved. Topics addressed include cardiopulmonary interactions, the pathophysiology of and strategies to minimize the development of ventilator-induced low cardiac output syndrome, common postoperative physiologies, perioperative bleeding and coagulation, and common postoperative complications.
View details for DOI 10.1542/peds.2022-056415J
View details for PubMedID 36317971
Assessment of fluid balance after neonatal cardiac surgery: a description of intake/output vs. weight-based methods.
Pediatric nephrology (Berlin, Germany)
BACKGROUND: Fluid overload associates with poor outcomes after neonatal cardiac surgery, but consensus does not exist for the most clinically relevant method of measuring fluid balance (FB). While weight change-based FB (FB-W) is standard in neonatal intensive care units, weighing infants after cardiac surgery may be challenging. We aimed to identify characteristics associated with obtaining weights and to understand how intake/output-based FB (FB-IO) and FB-W compare in the early postoperative period in this population.METHODS: Observational retrospective study of 2235 neonates undergoing cardiac surgery from 22 hospitals comprising the NEonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) database.RESULTS: Forty-five percent (n=998) of patients were weighed on postoperative day (POD) 2, varying from 2 to 98% among centers. Odds of being weighed were lower for STAT categories 4 and 5 (OR 0.72; 95% CI 0.53-0.98), cardiopulmonary bypass (0.59; 0.42-0.83), delayed sternal closure (0.27; 0.19-0.38), prophylactic peritoneal dialysis use (0.58; 0.34-0.99), and mechanical ventilation on POD 2 (0.23; 0.16-0.33). Correlation between FB-IO and FB-W was weak for every POD 1-6 and within the entire cohort (correlation coefficient 0.15; 95% CI 0.12-0.17). FB-W measured higher than paired FB-IO (mean bias 12.5%; 95% CI 11.6-13.4%) with wide 95% limits of agreement (-15.4-40.4%).CONCLUSIONS: Weighing neonates early after cardiac surgery is uncommon, with significant practice variation among centers. Patients with increased severity of illness are less likely to be weighed. FB-W and FB-IO have weak correlation, and further study is needed to determine which cumulative FB metric most associates with adverse outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
View details for DOI 10.1007/s00467-022-05697-w
View details for PubMedID 36066771
Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration.
Importance: Preventing in-hospital cardiac arrest (IHCA) likely represents an effective strategy to improve outcomes for critically ill patients, but feasibility of IHCA prevention remains unclear.Objective: To determine whether a low-technology cardiac arrest prevention (CAP) practice bundle decreases IHCA rate.Design, Setting, and Participants: Pediatric cardiac intensive care unit (CICU) teams from the Pediatric Cardiac Critical Care Consortium (PC4) formed a collaborative learning network to implement the CAP bundle consistent with the Institute for Healthcare Improvement framework; 15 hospitals implemented the bundle voluntarily. Risk-adjusted IHCA incidence rates were analyzed across 2 time periods, 12 months (baseline) and 18 months after CAP implementation (intervention) using difference-in-differences (DID) regression to compare 15 CAP and 16 control PC4 hospitals that chose not to participate in CAP but had IHCA rates tracked in the PC4 registry. Patients deemed at high risk for IHCA, based on a priori evidence-based criteria and empirical hospital-specific criteria, were selected to receive the CAP bundle. Data were collected from July 2018 to December 2019, and data were analyzed from March to August 2020.Interventions: CAP bundle included 5 elements developed to promote increased situational awareness and communication among bedside clinicians to recognize and mitigate deterioration in high-risk patients.Main Outcomes and Measures: Risk-adjusted IHCA incidence rate across all CICU admissions (IHCA events divided by all admissions).Results: The bundle was activated in 2664 of 10 510 CAP hospital admissions (25.3%); admission characteristics were similar across study periods. There was a 30% relative reduction in risk-adjusted IHCA incidence rate at CAP hospitals (intervention period: 2.6%; 95% CI, 2.2-2.9; baseline: 3.7%; 95% CI, 3.1-4.0), but no change at control hospitals (intervention period: 2.7%; 95% CI, 2.3-2.9; baseline: 2.7%; 95% CI, 2.2-3.0). DID analysis confirmed significantly reduced odds of IHCA among all admissions at CAP hospitals compared with control hospitals during the intervention period vs baseline (odds ratio, 0.72; 95% CI, 0.56-0.91; P=.01). DID odds ratios were 0.72 (95% CI, 0.53-0.98) for the surgical subgroup, 0.74 (95% CI, 0.48-1.14) for the medical subgroup, and 0.72 (95% CI, 0.50-1.03) for the high-risk admission subgroup at CAP hospitals after intervention. All-cause risk-adjusted mortality rate did not change after intervention.Conclusions and Relevance: Implementation of this CAP bundle led to significant IHCA reduction across multiple pediatric CICUs. Future studies may determine if this bundle can be effective in other critically ill populations.
View details for DOI 10.1001/jamapediatrics.2022.2238
View details for PubMedID 35788631
Fluid Accumulation After Neonatal Congenital Cardiac Surgery; Clinical Implications and Outcomes.
The Annals of thoracic surgery
To determine the association between fluid balance metrics and mortality and other postoperative outcomes after neonatal cardiac surgery in a contemporary multi-center cohort.Observational cohort study across 22 hospitals in neonates (≤30 days) undergoing cardiac surgery. We explored overall % fluid overload, postoperative day 1 % fluid overload, peak % fluid overload, and time to first negative daily fluid balance. The primary outcome was in-hospital mortality. Secondary outcomes included postoperative duration of mechanical ventilation, and intensive care unit (ICU) and hospital length of stay. Multivariable logistic or negative binomial regression was used to determine independent associations between fluid overload variables and each outcome.The cohort included 2223 patients. In-hospital mortality was 3.9% (n=87). Overall median peak % fluid overload was 4.9%, (interquartile range 0.4-10.5%). Peak % fluid overload and postoperative day 1 % fluid overload were not associated with primary or secondary outcomes. Hospital resource utilization increased on each successive day of not achieving a first negative daily fluid balance and was characterized by longer duration of mechanical ventilation (incidence rate ratio 1.11, 95% confidence interval 1.08-1.14, ICU length of stay (incidence rate ratio 1.08, 95% confidence interval 1.03-1.12), and hospital length of stay (incidence rate ratio 1.09, 95% confidence interval 1.05-1.13).Time to first negative daily fluid balance, but not % fluid overload is associated with improved postoperative outcomes in neonates after cardiac surgery. Specific treatments to achieve an early negative fluid balance may decrease postoperative care durations.
View details for DOI 10.1016/j.athoracsur.2021.12.078
View details for PubMedID 35245511
- Reply to: Acute kidney injury after in-hospital pediatric cardiac arrest RESUSCITATION 2021; 163: 209-210
Meningitis and high-grade, second-degree atrioventricular block in an adolescent: causal effect or coincidence?
Cardiology in the young
We describe an adolescent with Streptococcus pneumoniae meningitis and symptomatic high-grade, second-degree atrioventricular block requiring permanent pacemaker placement. It is difficult to ascertain if these two diagnoses were independent or had a causal relationship though ongoing symptoms were not present prior to the infection. Because of this uncertainty, awareness that rhythm disturbances can be cardiac in origin but also secondary to other aetiologies, such as infection, is warranted.
View details for DOI 10.1017/S1047951121001785
View details for PubMedID 33966681
A Scoping Review of Health Information Technology in Clinician Burnout
APPLIED CLINICAL INFORMATICS
2021; 12 (03): 597-620
Clinician burnout is a prevalent issue in healthcare, with detrimental implications in healthcare quality and medical costs due to errors. The inefficient use of health information technologies (HIT) is attributed to having a role in burnout.This paper seeks to review the literature with the following two goals: (1) characterize and extract HIT trends in burnout studies over time, and (2) examine the evidence and synthesize themes of HIT's roles in burnout studies.A scoping literature review was performed by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with two rounds of searches in PubMed, IEEE Xplore, ACM, and Google Scholar. The retrieved papers and their references were screened for eligibility by using developed inclusion and exclusion criteria. Data were extracted from included papers and summarized either statistically or qualitatively to demonstrate patterns.After narrowing down the initial 945 papers, 36 papers were included. All papers were published between 2013 and 2020; nearly half of them focused on primary care (n = 16; 44.4%). The most commonly studied variable was electronic health record (EHR) practices (e.g., number of clicks). The most common study population was physicians. HIT played multiple roles in burnout studies: it can contribute to burnout; it can be used to measure burnout; or it can intervene and mitigate burnout levels.This scoping review presents trends in HIT-centered burnout studies and synthesizes three roles for HIT in contributing to, measuring, and mitigating burnout. Four recommendations were generated accordingly for future burnout studies: (1) validate and standardize HIT burnout measures; (2) focus on EHR-based solutions to mitigate clinician burnout; (3) expand burnout studies to other specialties and types of healthcare providers, and (4) utilize mobile and tracking technology to study time efficiency.
View details for DOI 10.1055/s-0041-1731399
View details for Web of Science ID 000670383100003
View details for PubMedID 34233369
View details for PubMedCentralID PMC8263130
- Commentary: The Vulcan mind MELD-XI. The Journal of thoracic and cardiovascular surgery 2021
- Real-Time, Secure, and Confidential Data Sharing in the Fight Against COVID-19 and Beyond Cincinnati Children's Hospital Medical Center Research Horizons. 2021
Acute kidney injury after in-hospital cardiac arrest.
Determine 1) frequency and risk factors for acute kidney injury (AKI) after in-hospital cardiac arrest (IHCA) in the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital (THAPCA-IH) trial and associated outcomes; 2) impact of temperature management on post-IHCA AKI.Secondary analysis of THAPCA-IH; a randomized controlled multi-national trial at 37 children's hospitals.Serum creatinine (Cr) within 24 h of randomization.Prevalence of severe AKI defined by Stage 2 or 3 Kidney Disease Improving Global Outcomes Cr criteria. 12-month survival with favorable neurobehavioral outcome. Analyses stratified by entire cohort and cardiac subgroup. Risk factors and outcomes compared among cohorts with and without severe AKI.Subject randomization: 159 to hypothermia, 154 to normothermia. Overall, 80% (249) developed AKI (any stage), and 66% (207) developed severe AKI. Cardiac patients (204, 65%) were more likely to develop severe AKI (72% vs 56%,p = 0.006). Preexisting cardiac or renal conditions, baseline lactate, vasoactive support, and systolic blood pressure were associated with severe AKI. Comparing hypothermia versus normothermia, there were no differences in severe AKI rate (63% vs 70%,p = 0.23), peak Cr, time to peak Cr, or freedom from mortality or severe AKI (p = 0.14). Severe AKI was associated with decreased hospital survival (48% vs 65%,p = 0.006) and decreased 12-month survival with favorable neurobehavioral outcome (30% vs 53%,p < 0.001).Severe post-IHCA AKI occurred frequently especially in those with preexisting cardiac or renal conditions and peri-arrest hemodynamic instability. Severe AKI was associated with decreased survival with favorable neurobehavioral outcome. Hypothermia did not decrease incidence of severe AKI post-IHCA.
View details for DOI 10.1016/j.resuscitation.2020.12.023
View details for PubMedID 33450335
IMPROVING NURSE EMPOWERMENT DURING CARDIAC ARREST PREVENTION HUDDLES IS RELATED TO DECREASED ARREST
LIPPINCOTT WILLIAMS & WILKINS. 2020
View details for Web of Science ID 000530000201644
- Commentary: I am not throwing away my shot . . . to predict when your patient will decompensate JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 158 (1): 246-247
- Commentary: Fontan survivor-outwit, outlast, outplay but do not overstay (your welcome) JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 157 (5): 2014-2015
Fluid overload independent of acute kidney injury predicts poor outcomes in neonates following congenital heart surgery.
Pediatric nephrology (Berlin, Germany)
Fluid overload (FO) is common after neonatal congenital heart surgery and may contribute to mortality and morbidity. It is unclear if the effects of FO are independent of acute kidney injury (AKI).This was a retrospective cohort study which examined neonates (age < 30 days) who underwent cardiopulmonary bypass in a university-affiliated children's hospital between 20 October 2010 and 31 December 2012. Demographic information, risk adjustment for congenital heart surgery score, surgery type, cardiopulmonary bypass time, cross-clamp time, and vasoactive inotrope score were recorded. FO [(fluid in-out)/pre-operative weight] and AKI defined by Kidney Disease Improving Global Outcomes serum creatinine criteria were calculated. Outcomes were all-cause, in-hospital mortality and median postoperative hospital and intensive care unit lengths of stay.Overall, 167 neonates underwent cardiac surgery using cardiopulmonary bypass in the study period, of whom 117 met the inclusion criteria. Of the 117 neonates included in the study, 76 (65%) patients developed significant FO (>10%), and 25 (21%) developed AKI ≥ Stage 2. When analyzed as FO cohorts (< 10%,10-20%, > 20% FO), patients with greater FO were more likely to have AKI (9.8 vs. 18.2 vs. 52.4%, respectively, with AKI ≥ stage 2; p = 0.013) and a higher vasoactive-inotrope score, and be premature. In the multivariable regression analyses of patients without AKI, FO was independently associated with hospital and intensive care unit lengths of stay [0.322 extra days (p = 0.029) and 0.468 extra days (p < 0.001), respectively, per 1% FO increase). In all patients, FO was also associated with mortality [odds ratio 1.058 (5.8% greater odds of mortality per 1% FO increase); 95% confidence interval 1.008,1.125;p = 0.032].Fluid overload is an important independent contributor to outcomes in neonates following congenital heart surgery. Careful fluid management after cardiac surgery in neonates with and without AKI is warranted.
View details for PubMedID 29128923
The Effects of Sleep Extension on the Athletic Performance of Collegiate Basketball Players
2011; 34 (7): 943-950
To investigate the effects of sleep extension over multiple weeks on specific measures of athletic performance as well as reaction time, mood, and daytime sleepiness.Stanford Sleep Disorders Clinic and Research Laboratory and Maples Pavilion, Stanford University, Stanford, CA.Eleven healthy students on the Stanford University men's varsity basketball team (mean age 19.4 ± 1.4 years).Subjects maintained their habitual sleep-wake schedule for a 2-4 week baseline followed by a 5-7 week sleep extension period. Subjects obtained as much nocturnal sleep as possible during sleep extension with a minimum goal of 10 h in bed each night. Measures of athletic performance specific to basketball were recorded after every practice including a timed sprint and shooting accuracy. Reaction time, levels of daytime sleepiness, and mood were monitored via the Psychomotor Vigilance Task (PVT), Epworth Sleepiness Scale (ESS), and Profile of Mood States (POMS), respectively.Total objective nightly sleep time increased during sleep extension compared to baseline by 110.9 ± 79.7 min (P < 0.001). Subjects demonstrated a faster timed sprint following sleep extension (16.2 ± 0.61 sec at baseline vs. 15.5 ± 0.54 sec at end of sleep extension, P < 0.001). Shooting accuracy improved, with free throw percentage increasing by 9% and 3-point field goal percentage increasing by 9.2% (P < 0.001). Mean PVT reaction time and Epworth Sleepiness Scale scores decreased following sleep extension (P < 0.01). POMS scores improved with increased vigor and decreased fatigue subscales (P < 0.001). Subjects also reported improved overall ratings of physical and mental well-being during practices and games.Improvements in specific measures of basketball performance after sleep extension indicate that optimal sleep is likely beneficial in reaching peak athletic performance.
View details for DOI 10.5665/SLEEP.1132
View details for Web of Science ID 000292926500022
View details for PubMedID 21731144
View details for PubMedCentralID PMC3119836