Andersons pediatric cardiology 2262
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mosthealthcaresettings,withveryimpressivereturnsoninvestmentsinterms
ofimprovingoutcomesandloweringcostsofcare.63
MultidrugResistance.
Theemergenceofmultidrugresistantbacterialpathogensposesperhapsthemost
seriouschallengetomanagementofsickinfantsandnewbornswithheartdisease
inLMICenvironments.Widespreadindiscriminateuseofbroad-spectrum
antibioticsinthecommunityandinhospitalshasundoubtedlycontributedtothis
unfortunatepredicament.64Antibioticstewardshipinitiativeshavearolein
mitigatingtheprobleminpediatricheartprograms.Theyhavebeenshownto
substantiallyreducethecostofcare.
OtherInfections.
AnumberofotherinfectionsoccurinthecommunityintheLMICsetting(see
Table88.4).Theyhavethepotentialtosignificantlycomplicatethemanagement
ofCHD,andthisisparticularlytrueforopenheartsurgery.
DeliveringPediatricHeartCareinResourceLimitedEnvironments
Itisabundantlyclearthattheoverwhelmingmajorityoftheworld'schildrenlive
inpartsoftheworldwithsubstantiallimitationsinresourcesandsystemsto
deliverbasicpediatricheartcare.Yetmuchofthecontemporaryscientific
literaturefocusesonnicheareasandveryspecificissuesthataffecttherelatively
smallpatientpopulationsinadvancednations.20Althoughtheseissuesareof
someinteresttoeveryone,theavailablesciencedoesnotenableusto
satisfactorilyaddressaveryfundamentalissue:Howcanwedeliver
comprehensivequalitycarefortheaveragechildwithheartdiseaselivingina
resource-constrainedenvironment?
Inthepast2decadesanumberofnewpediatricheartprogramshavebeen
establishedinLMICs.Alltheseprogramshavetocontendwiththechallengeof
deliveringpediatricheartcareinthefaceofsignificantlimitationsinhumanand
materialresources.Thissectionwilldescribethegeneralprinciplesthatgovern
thisprocess.
GeneralPrinciples
Toovercomethesechallengesitisnecessarythatallmembersoftheteam
embracethephilosophyofworkingtoreachouttothelargestpossiblenumberof
affectedchildrenwiththeavailableresources.20Alistofattributesthatis
particularlyusefultowardthisendislistednext.Pediatriccardiacprofessionals
(cardiologists,cardiacsurgeons,intensivists,anesthesiologists,andnurses)who
workinresource-constrainedenvironmentswillneedtoacquiretheseattributes
inadditiontotheircoreclinicalskillsinordertobeeffective.
1.Adeep-rooteddesiretoreachouttoandservetheneedsoftheaverage
childintheregion.Thereisperhapsanevengreaterneedtounderstand
thesocioeconomicandculturalbackgroundoffamilies,aswellas
logisticchallengesthatthefamiliesface.Thisenablesdevelopmentof
thoughtfulandcontextuallyappropriatemanagementstrategies
recognizingthechallengesthatindividualfamiliesface.
2.Willingnesstomultitask.Theluxuryofhavingspecialistswithspecific
domainsofexpertiseinvariouselementsthatconstitutecomprehensive
pediatriccardiaccare(seeFig.88.4)isnoteconomicallyviablein
resource-constrainedenvironments.Awiderangeofskillsmayhaveto
beacquiredtoeffectivelyfunctioninvariedsituations.Forexample,it
maybenecessaryforthesamepediatriccardiologisttodoimaging
work,performcatheterinterventions,assistinintensivecare,and
interpretcommonarrhythmiasatthebedside.Someoftheseskillsare
quitecomplementaryandoftenhelptoimproveoverallefficiency.
3.Willingnesstoimproviseandinnovate.Anumberofinnovationsin
variousfacetsofpediatricheartcarefromresource-poorenvironments
haveenabledcostreductionswithoutcompromiseinquality.Someof
theseinnovationscanalsobeusedinadvancednationstohelpreduce
healthcarecosts.Table88.5listsexamplesoflow-costinnovationsin
catheterinterventionsthatcanbeuseinlow-resourcesettingswithout
significantcompromiseinquality.
Table88.5
InnovationsandAdaptationstoReduceCostsofPediatricCardiac
Catheterization
SourceofExpense
ExpenseofBiplane
catheterization
Low-CostSolution
Asingleplanecathlaballowssafeandeffectivediagnosticand
interventionalcatheterizationinmorethan95%ofsituations.Sharingthe
laboratory
Expenseofhybrid
catheterization
laboratory
Longprocedure
timesofpediatric
catheterization
Catheterhardware:
Requirementofa
largeinventoryof
dedicatedhardware
forpediatricheart
catheterization
Costofocclusive
devices
Generalanesthesia
cathlabwithanadultfacilityallowssubstantialreductionsinequipment
overheadperprocedure.Liberaluseofechocardiographytosupplement
imagingforcatheterinterventionhelpsinovercominglimitationsof
biplaneimaging.
Giventhetinyproportionofcasesthattrulyneedhybridcatheterization
laboratoryitisdifficulttojustifytheoverheadexpenseforcasesthatdo
notneedthem.Carefulpreoperativeimagingandplanningallowshybrid
stentingofbranchpulmonaryarteriescanbeperformedintheoperation
roomunderdirectvisionwithoutfluoroscopicguidance.
Meticulousechocardiographybeforetheprocedurebythesameperson
doingthecatheterizationallowsfocusedortargetedproceduresthat
considerablyreduceproceduretime.
Improvisationsinusingadulthardwareforpediatriccatheterization.For
example,anumberofcoronaryangioplastyhardwareitemsareactually
wellsuitedfornewborninterventionssuchasstentingoftheductandthe
rightventricularoutflowtract.Resterilizationandreuseofcatheterscan
besafelyundertakenincarefullymonitoredsettings.
Gianturcocoilscanbeusedaslow-costalternativesforocclusivedevices
inselectedsituations.Thebioptome-assistedtechniquesenables
simultaneousdeliveryofmultiplecoils.78Thiscanbeusedforlarge
vesselsandselectedpatentarterialducts.
Usingcarefullyimplementedsedationprotocolsandcomfortablepatient
restraints,themajorityofcatheterinterventionscanbeundertakenwith
conscioussedationwithouttheneedforgeneralendotrachealanesthesia.
Thissavestimeandresources.
4.Developpragmaticcaseselectionstrategies.Itisanethicalchallengeto
denycaretoanindividualpatientwithacomplexconditiontopreserve
thelargerinterestsofafragilesystem.Examplesincludeprioritizing
patientswithstraightforwardlesionscorrectablethroughasingle
operationovercomplexmultistagedproceduressuchaspalliationforthe
hypoplasticleftheartsyndrome.65
5.Willingnesstotailorsolutionsaccordingtothesocioeconomiccondition
ofthefamilies.Deviationsfrom“standard”practicearecommoninthe
faceofeconomicconstraintsparticularlywhenfamilieshavetopayout
ofpocket.Forexample,theinabilitytoaffordaconduitmaynecessitate
palliationwithacavopulmonaryshuntinaninfantorayoungchildwith
transposition,VSD,andpulmonarystenosis.
6.Reluctancetoacceptexpensivenewtechnologywithoutproofof
incrementalbenefits.Althoughitistruethattechnologicadvanceshave
contributedsubstantiallytowardimprovingtheoutcomesofchildren
withheartdisease,itisalsotruethatveryexpensivenewtechnologyhas
oftenfounditswayintomainstreampracticewithoutanyformofaudit
oncostversusincrementalbenefit.Examplesofsuchhigh-end
