This symposium honored Abraham M. Rudolph, MD and showcased his significant contributions to the field of congenital heart disease.The event focused on the continuum of care, from prenatal detection to advancements in neonatal cardiac and neurodevelopmental care. Read Dr. Norman Silverman’s tribute to Dr. Rudolph to learn more about his life and legacy.
Must have it. It and so he call is just it. Yeah. Go them on your and they, yeah, I, he go them on your to one thing. Don't see to just look at right parents were that you slowly go them on your, they one. So just look at the of Paris seem somehow sadly gay. The glory that was wrong is of another. Were I have been terribly alone and forgotten. Amen. I'm going home to my city by. Mhm. I left my and for hi, it called to Cable car. Yes, to the star. My love way. Yeah. Above well, thanks everybody for coming. Um, I don't have any prepared remarks. I think it's hard to actually prepare for, uh, something like uh like this symposium. We initially uh had planned to do, uh a symposium uh before Doctor Rudolph passed away and uh it became very clear that it should be done in his honor uh as we drew closer to the World Congress. So I, I really want to thank all of you for coming. Our original MC was to be Jeff Feinman. He's not able to, uh to be here today. And so I hope that you enjoyed the video. And we're going to invite some of uh Doctor Rudolph's former fellows to the stage to just give a few remarks. Um And uh towards the end, if, if any of you have some fond memories, please uh get up to share and then we'll have uh a, a few brief presentations uh highlighting the program and the state of the program. Now at U CS F uh where Doctor Rudolph spent so many decades, Norman Silverman is the uh the man who usually needs no introduction. But as he, as he tells me, he is the most senior fellow in the room. And uh I think I'll leave it at that Norman. Thank you. Thank you very much, everybody. And it's a great honor to be here to honor Abraham Rudolph. I am the senior fellow. My fellowship ended in 1974. Dr Rudolph kicked me out and sent me to Stanford, but I didn't stay there long. So I wanted to uh just bring out uh in the memory of this marvelous man. The um three things. Firstly, I wanted to talk about him as a researcher because he really was quite an amazing person. Uh We used to have the uh sheep lab uh right next to his office and he would often come out of the office, pick up a broom and a scooper and clean up all of the uh sheep droppings. He never failed to keep his lab clean uh when he operated and, and he was a magnificent operator. I don't know whether anybody ever knows that despite his terrible intention, tremor, he was an amazing catheterize and did AAA huge amount of development of the sheep model as we all know it. He was never uh ask AAA fellow or a technician to finish the operation by showing a patch on the sheep's skin. He did everything himself. So he really did lead in many ways by example. And I think we have to remember him primarily as a sheep fetal physiologist. Secondly, I thought that I would like to tell you something about him that you don't know because he stood about 5 ft six inches high and was really quite a slender man with not a huge physique, but he was one of the toughest people you ever met. I was with him one year in Venice, it was freezing. He had just a sports coat on and I kept on asking him if he'd wanted something else. And he said, no, I never get cold. What he didn't tell me is he also had a broken toe and he walked all over Venice with a broken toe without any sign of limping or without any complaints. Lastly, I want to tell you about uh Abe's last illness, which was so unfortunate, uh, and robbed him of his century as he was sitting on his couch one day and uh he slipped off the couch and broke his hip and he went for a hip replacement and that worked well, but he had actually a hip replaced previously and developed in that hip septic arthritis, which was not adequately treated. He got a fluoroquin uh antibiotic which as you know, causes uh, tendon ruptures and he ruptured both of his achilles tendons so he couldn't walk. And also because of that, he fell and he ruptured his rotator cuff. So he was really quite physically disabled, which was extremely difficult for him. Um What happened with the, the fact of his inadequate treatment of his uh septic arthritis is that he developed infective endocarditis. Unfortunately, on his mitral valve and ruptured the tenderness cords on his mitral valve. I uh and Colin Rudolph, his son's behest arranged for him to be admitted to uh UC San Francisco and he was admitted actually to the ward in the old hospital which had been converted to a cardiac intensive care unit. So, Abe was back on his own ward. Unfortunately, because of the rupture, he was not able to get a micro clip on his valve and he declined to have surgery and entered hospice and died shortly after that. He was certainly to me, a very important person. Our roots are exactly the same from Lithuania in Europe. And our parents were immigrants from that region. His brothers that you saw there in the see, no evil speak, no evil. Hear no evil triumph for it were our family physicians and our families were closely related. So his passing is for me, a real sadness as it is. I'm sure for all of you. Thank you. You. Ok, thank you Norman. That was so touching. And um yeah, we're we are all going to miss him and uh remember him walking on those, those wards uh and torturing us as well with the how brilliant he was. Uh there was never a question that, that he could ask that he didn't know the answer to, but usually nobody else in the room would know. And so we learned so much from him. Um So the next uh person who wanted to say a few words is Wayne Totsky. He's uh another man who needs no introduction. But Wayne actually was also one of uh Norman's fellows in a slightly different era from Doctor Silverman. So Wayne, please come up. Good morning everyone. Thanks for coming here, getting up so early. Um And actually, I know what you meant. Abe's fellows who said Norman's fellows. True. That's true. Actually, I first met Dr Rudolph in 1993 when I started pediatric residency at UCSF. And at the time he was actually still attending on the general pediatric ward. He would to do morning report and then he would do the famous Rudolph rounds on a Friday in the nursery where one of the residents would present a case to him and he would just go off on a tangent for an hour. It was just incredible. And if only we had cell phones in those days to record these sessions, I mean, really they were just, each session was a text, but it was incredible. And uh and so he really, he, he was at the, at the time, he was really chairman of pediatrics and cardiology. I'm not sure there's anyone who does that today, but he was actually capable of doing both and did an excellent job with both. And really shortly after I arrived, he stepped down as chair of pediatrics. And then actually the day I started fellowship, he stepped down as chief of cardiology. So technically, I was never actually his fellow under him, but he was still there and uh and was an incredible mentor to discuss research projects with and just general life and career advice. So it was really uh sort of became, became a friend. And I actually was fortunate not to be one of his fellows in the sense that I didn't have to uh you know, be tortured by him. Like many of the other fellows were, it was a much more uh friendly relationship. And then I, I went to Boston Children's Hospital, which is of course, where Doctor Rudolph started, I believe in Norman, you may know that you're 49 or 52 52 he was a fellow. Uh and they still talk about some of the legendary stories of course, there are many one of the legendary stories uh uh is that doctor who was his chief went on sabbatical because in those days they got sabbaticals. We don't. And Abert started cat patients, but they had never done cats on neonates. And so while the chief was away, Abe decided to start doing cats on neonates. Uh in those days, I don't think they were the same regulations and IRB and anyway, they started doing a bunch of cats on neonates and doctor came back and then another patient, they decided that uh uh they had some diagnostic difficulties and uh uh and Abe said, I think we should catch the patient. And doctor said we can't do that. He said, well, I've already done seven cases while you were away. And so that was how he did that. And I guess these days you get fired for doing things like that. Um And uh and um we were very fortunate um in 2016, at age 93 we invited him to come and spend some time with us and he spent three days meeting with the fellows giving talks, meeting with faculty, listening to re research presentations. And that was capped off by an evening of him talking about the history of pediatric cardiology in general. And in particular, he gave a talk about the woman in pediatric cardiology. Uh starting way back with Mad Abbott and you know, uh uh Helen and and, and many others. Uh and then followed by an interview with Mike Fried, which went on for an hour and they just kept, kept talking. It was incredible. Um And um yeah, overall, it was a, it was a, it was a great friend and mentor to have a collection of incredible emails from him asking me questions which I still don't know the answer to. Um And uh but yeah, overall, it's just an incredible human being and really fortunate to have had a relationship with him uh and friendship over the last almost 30 years now. So thank you for all for attending. And uh we look forward to the, the, the meeting. Oh, thank you so much, Wayne. You don't have to, you can stay, you can stay. Um Well, I certainly wasn't uh one of Doctor Rudolph's fellows per se. I came right after Wayne. Um but I, I do have the uh the uh perspective of he came to San Francisco in 66 or 67 before I was born. And I feel like it's such a privilege to have uh interacted with and been taught by going to seminars and discuss my own research uh with uh with a, I'm wondering how just curiosity, how many people in the room uh were trained by Doctor Rudolph were either fellows or seminars or? And everybody over here too, is there anyone else who would like to say a few words before we uh get on with this scientific program and that's completely fine. Doctor Rudolph actually did not want a, uh, a funeral, a memorial. Uh, any of those things. I think we all keep him uh, in our hearts and certainly in our everyday, uh, in our everyday work. Um, so a big thank you to, uh, to Doctor Rudolph for everything that he has given to pediatric cardiology and to us as physicians, pediatricians and people. Can we have the slides, please? Do you want me to go through this or just skip through it? I'll be here to thank. Ok. Um The next few slides, I'm going to skip through in the interest of time. But uh Doctor Silverman has mentioned to me that he wrote a very, very nice uh piece on Doctor Rudolph uh just this past couple of months ago and which journal is it in, it's in cardiology of the young cardiology and the young. And there's also a thing called, uh I read off the history published some years earlier on from which most of these slides have been extracted. Ok, I looked at these slides the other day and the honors and awards went on forever and ever. Um This is uh as Doctor Rudolph and his wife, Rona, who preceded him in death and who I think Norman wants to say something about that house that you see is called Kallay, which is African for my house. And unfortunately, in the Sonoma fire that we had a couple of years ago, the whole house was totally burned down with all of its priceless collections has been rebuilt by his family. Ok. So I promised you a little bit of science. We're gonna talk uh just for the next few minutes as you uh finish your breakfast about managing premature newborns with complex congenital heart defects from the fetal to the neonatal period. I'm going to speak first and to be rapidly followed by Doctor Mins. So Kim who is one of our uh cardiac intensivist, also trained in neonatology and has been part of our efforts in uh really improving the care of these tiny babies who have so many special uh requirements. I get the easy part to remind us all about the fetal and transitional physiology and how it informs our care of these patients. We think of fetal heart care as taking pictures, doing tests, talking to the patients and spending a lot of time preparing the family and the post natal teams for a particular diagnosis that we have arrived at with our imaging. But every time that I touch a probe, what I'm thinking about is predicting what the postnatal anatomy is going to be based on the imaging now and about progressive lesions and what this could look like in two months or three months or even six months. And then trying to predict the trans transitional and postnatal physiology of what I'm seeing in utero with nothing other than an ultrasound probe, no saturation probe, no physical exam, no presentation really as most of these babies are stable in utero. And then to prepare the team with that uh information. And we get this all from uh Doctor Rudolph's early work. He is the one that uh told us that the combined ventricular output in the human fetus is similar to that in the lamb that the right ventricle is dominant and supplies the lower body and placenta. And that the left ventricle uh is only responsible for 40 to 45% of the combined output in utero, which explains, excuse me, some of the things that uh that we're seeing in the fetus that we don't see later on including the low pulmonary blood flow 17% in this model. He also uh did extensive work on intravascular pressure in the lamb showing that the right atrial pressure is slightly higher than the left, driving the right to left atrial shunt in utero, that the pressures in the ventricles are equal and in the aorta and main pulmonary artery and duct are equal. Therefore, making things like gradients. Uh a much more difficult thing to interpret and lack of gradients, not something that uh is useful in fetal obstructive heart disease. Sorry, I forgot, I animated all of those. Uh He but he goes further than that and looks at intravascular pressures in the uh human fetus and shows us that impedance that is seen by the left ventricle is higher uh because it's ejecting into a less compliant bed, that's the brain and the resistor, the aortic isthmus that was only carrying about 10% of the combined ventricular output in utero. And the lower compliance placenta seen by the right ventricle serves to unload and uh and allow uh rapid rise and early peak and a higher stroke volume from the right ventricle. So it all makes sense. He also challenged the old concept that fetal myocardium doesn't have the same starling curve that adult myocardium has. By showing that the uh left atrial pressure increases. Uh the increasing the left atrial pressure does increase the stroke volume of the ventricle if after load is controlled. And then of course, his uh really uh amazing work on the transitional circulation, the transition of the pulmonary circulation with the drop in pulmonary vascular resistance and increase in pulmonary blood flow that happens immediately after birth. So, with all of this information on what the fetal circulation is like and how it's different from the postnatal circulation and how the transition happens and how quickly we have been able to over the years develop specialized uh delivery room planning for fetuses who have congenital heart disease and to expect certain lesions to be stable in the delivery room while also anticipating, potentially unstable neonates in the delivery room. Things such as ductal dependent heart disease. We know this now because the fetus can redirect flow to one or the other ventricles. When the contralateral ventricle is obstructed. And the fetal ability to do that through the fetal shunts is uh more elegant work that Doctor Rudolph uh led us through. So for instance, the left to right atrial shunt in critical aortic obstruction tells us that that's going to be ductal dependent or right to left uh uh shunting at uh at other levels. So, we know when fetuses are going to be ductal dependent because of the physiology, not necessarily the anatomy alone, we also can anticipate intervention dependent fetuses with abnormal left atrial pressure in patients who have uh limitation to left atrial egress, such as hypoplastic left heart syndrome with intact atrial septum. And finally, we know which fetuses are still at risk are at risk when they are still in utero, those with severe uh regurgitant lesions, those that are not being helped by after loading, by reducing the afterload to the right ventricle. And that those patients may improve with delivery. For instance, Epstein's malformation of the tricuspid valve not stable while the main pulmonary artery pressure is high in utero but much better when we can rapidly drop the pulmonary vascular resistance and really unload the right ventricle. Uh after birth, this information then becomes uh sort of a thought experiment with patients like this one with a single ventricle, total anomalous pulmonary venous return below the diaphragm, which looks a bit obstructed there on the right and pulmonary stenosis or atresia reduced pulmonary blood flow with obstructed, total anomalous pulmonary venous return. I'm not gonna look at the gradient here. I'm gonna look at the flows because there's not a lot of blood flow going through the lungs. We know that from Doctor Rudolph. So immediately after birth, I expect this fetus who's fine in utero to be critically ill. The gradient there through the vertical vein is only about three millimeters of mercury, but this is going to be a very sick baby. And we know that based on the physiology and we can plan for that. This fetus. On the other hand, also has total anomalous pulmonary venus return but has fairly normal looking flows and is going to be unobstructed. And so we use our physiology and our anatomy, our imaging skills and our knowledge to plan for deliveries and to manage the perinatal period to decide where when, how and why to improve outcomes including morbidity, mortality and neurodevelopmental and functional status that we're going to hear more about uh in the upcoming lectures. We have focused also on potentially modifiable factors that may have an effect on outcome including uh the knowledge that optimal early outcomes are associated with delivery as late as possible. 39 to 40 weeks, the patients born in early term have higher complication rates which we will also hear longer postoperative length of stay. Therefore, in the absence of maternal indications for earlier delivery, logistical advantages of delivering early, we have learned uh are deleterious to the fetus and should be avoided. I already mentioned some of the instances where we might recommend early delivery based on the fetal physiology including Epstein's and tetra of low heart block intact or severely restrictive atrial septum and obstructed T A PV R because we know that we can use delivery to rapidly change the physiology if it is uh causing harm to the fetus. And with that, I'd like to turn over to uh Doctor Min Kim. Uh she is uh as I said, a neonatal cardiac intensivist at U CS F. And she's going to talk about what happens after the delivery planning. Thank you for the introduction. Um Thank you for the introduction. Good morning. So, um in memory of Doctor Rudolph, I'll be talking about how we manage our premature newborns with complex congenital heart disease. So we all know that babies who are born young and small don't have as good of an outcome. Most of you here probably have read this study already by Doctor Costello that was published about 10 years ago. This is looking at the sts data on different um different gestation on age and how their mortality goes up the younger they are and it continues all the way until they are 39 to 40 weeks of gestation, just like like how doctor just spoke about. And that trend continues for the morbidities as well. This is um our very own, Doctor Martina at U CS F study. And that's looking at the outcomes such as rop chronic lung disease, um PV L brain bleeds and all the things that we care about. And they also increase as their gestational age is younger and the young. Um the complex congenital heart disease population have even more accent pattern, which is the orange bars here in comparison to the blue ones who do not have congenital heart disease. So with that in mind, I do want to share a little bit of our experiences at U CS F in the past a few years. So this graph shows the past seven years of a trend in terms of our index operations for neonates. The green one is a medium for all the PC four institutions. Um Thanks to our colleague and the blue one is our U CS F data which we operate about 70 to 80 neonatal cases per year for index operations and about 20% of those are preterm. Um And again, in this graph, this is an aggregate of the seven years from 2016 to 2022. And the green one is again, median for PC four and blue is U CS F. And for those um our median age for the preterm, newborns operated are 35 weeks of gestation and 2.26 kg of birth weight. But those two numbers don't quite capture the complexity of their heart lesions, anatomy and physiology and genetic abnormalities, any other extra cardiac abnormalities, because a lot of them do come um after being deemed to be inoperable or being a poor surgical candidate for other centers, either prenatally or post natally and thankfully end up having a decent outcome. So the survival to discharge rate is about 84% which is lower than our term population, which is at 91%. Um The hospital length of stay is about 37 days. In terms of what kind of structures we have instilled for caring for these babies. We have a couple of different elements. I'll be talking about the first two and Laurie Feynman, our wonderful clinical um specialist will be talking about the bottom three. So the surgeons can't really talk about our neonatal center without our neonatal surgeon. That's already is our primary neonatal surgeon. Um He's, he has wonderful outcomes. This is a paper from more than 20 years ago talking about how in his hands, babies who went through early full repair have great outcome. That doesn't seem to be different from the ones who went through stage repair. So in our center, we don't really have um uh weight and grow to a certain age or um we it's kind of a cut off. It's more of a where their path of physiology is when do they need to get operated and that governs our operated timing and bad management, but I won't go into that Um um So with the surgeons, we do weekly neonatal rounds in the and the C IC O. So every Monday at 7 30 neonatologists, surgeons, clinical nurse, specialist, cardiac intensivist, best side nurses all gather together and go through every single cardiac babies pre up and post up whether they're in the or in the cardiac IC O. So there we talk about the big picture of sharing the mental model of um surgical planning, timing, as well as some of the details um such as nutrition, feeding them by oral versus tube trophic or not. Um ventilation, oxygenation, whether do they need vascular access, pull out that umbilical line or not. Um And any other extra cardiac issues, there might be whether it be brain or kidney or liver, et cetera. In terms of the day to day management, we have a few guidelines that we share within our center. Um This is a screenshot of the wiki page that we have in our internal server. Um These are just some of the examples that I won't go into in terms of details, given the time. Um But we have certain guidelines for pre and post of feeding ventilation when they're activated uh depending on the risk stratification. Um Billy Rubin, et cetera, um If any of you would like to have the actual guidelines, please send me an email but not only that we share our guidelines, I'd also love to learn how other centers are managing these newborns because um we have learned so much from work and we also have learned a lot from other centers who are doing similar line of work even before we started doing it. So if you would like to share your guidelines with us, I'd always love to see it and learn more from it. Um With that, um we have a couple more steps that we have in our mind for future for Nava. We plan on implementing that by the end of this year. Um, next month, we will be starting officially weekly adjustment for medications and feeding and there are many other things that we have in our mind for fragile bones and isolate for little babies, et cetera. So, with that in mind, I will pass this on to doctor, um, who will be talking about the new development of our newborns, followed by Laurie Feynman, who's our nurse, um, specialist. Yeah. Hi, everybody. Thank you so much for being here early um, to help us, uh honor uh Abe's legacy. Um I'm shab Padi for those of you that don't know me. I'm an associate professor at pediatrics and I work with Anita in the um fetal program. So, um, Laurie and I, and I'm gonna introduce her in a, in a moment. Um, are gonna talk about, um, a little bit of our focus on the holistic approach to our newborns with cardiovascular disease. And I'm going to talk mostly about the research that has informed our clinical care in this particular area. Um I'm gonna start with uh a little bit of a historical context. Um And why we're so focused on the brain in our, in our unit. Um This is a uh picture from uh 2001 at UCFF. Um And the two individuals in this photo are uh Patrick mcquillan who might be here somewhere. Um And uh Stephen Miller, who was uh U CS F at the time and what they're working on is an MRI uh compatible incubator. Um That really allowed them to initiate a study that went on for about 20 years to image newborn babies brains, um and describe brain development and patterns of brain injury in um newborns with congenital heart disease. Um uh Today, that doesn't seem like a big deal to get an MRI before after surgery for a newborn, but at the time required a lot of coordination. Um a lot of detail around uh making sure there were no adverse events and a lot of convincing of the surgeons at the time to be able to do this to sort of study. Um So this was uh the study that they started in, in 2001 that really in earnest went on for about 20 years. Um and consisted of getting a both pre and post operative brain MRI mostly for patients with transposition of the great arteries and single ventricle patients and ultimately with the goal of bringing them back for neurodevelopmental testing. Um At various time points, there were many publications from this cohort and um I'm gonna highlight three of them that I think were the most important uh from this cohort. The first was uh this paper in the New England Journal of Medicine. Uh That Stephen uh was the first author on uh where they looked at brain development in newborns with congenital heart disease And specifically looking at these important metabolites in the brain and found that in full term babies with complex congenital heart disease, their brains were about 4 to 6 weeks, delayed and corresponded to what would typically be seen at 34 weeks for a premature neonate. The second major finding from this cohort was uh the fact that neonatal brain injury or acquired brain injury is very common and complex congenital heart disease. About two thirds of newborns uh have um a brain injury, a third acquired even before they go to the operating room. And then a third have newly acquired injury postoperatively and usually in in the form of white matter injury or stroke. And what's interesting about these injuries is that these were all discovered on the basis of a research protocol. So these, these babies never had any overt neurologic findings that prompted an MRI which there therefore, it was very important to understand whether it affected developmental outcomes later in life. And this is the third paper I want to highlight where we looked at the relationship between these early brain injuries and outcome and did find an independent association between um moderate to severe injury in the newborn period and worse motor outcomes in in later infancy. So these injuries that these patterns of injury that we are seeing in the newborn period do um affect outcome. So fast forward about 20 years, this study, like I said, went on for 20 years And recently, we were able to look at um some of the trends in these injuries. And this was really um the motivation behind this uh came from the fact that we knew there's been a lot of changes in how we care for these newborns in the intensive care unit. There's been technical advances in the operating room and we were very curious to see if this had affected any of these brain injury patterns uh in the newborn period. And it was interesting what we found in the preoperative period. Um There was really no change in brain injury rates over the 20 year period, but we saw a consistent decline in the in the post operative white matter injury rates over the 20 year period. A decline of about 20%. And interestingly, we um tried to understand why we might see this decline and it seemed that it was related to an improved hemodynamic state, primarily higher blood pressures in the 1st 24 hours postoperatively, that might might explain these findings. So this is sort of an example of how the change in clinical practice has really affected trends of, of these uh brain injuries that were seen in the newborn period. So, what are we seeing? What are we doing now? Um I think in the next um 2 20 years, we're, we're really expanding our research and focusing on different time, important time periods. The first is um the fetal period, understanding the relationship between fetal cardiovascular physiology and brain health. The second is a, is a focus on the perinatal transitional period and uh the relationship between that physiology and brain health in our patients. And then finally, the last is um uh understanding the additive effects of prematurity and congenital heart disease on brain health, which is very important to our center. Um Given that we have a, a high number of premature newborns that come through. So finally, I just want to um say a couple words uh about Doctor Rudolph who really has been a uh has and continues to be a lasting influence on our research program. And you can see that even as late as 2016 and 2018 where he was well into his nineties, he was still publishing um and specifically publishing on this relationship between fetal cardiovascular physiology and and the brain. And this his knowledge in this area really helped inform how we conducted our research programs and how we thought about the questions that we were asking um when I started at U CS F in 2013, uh Abe was I think 90 he was still coming to U CS F intermittently and it was such a privilege that I was able to work with him and talk with him about my research questions. Um And I'm just very grateful for that. So now I'm gonna pass it along to uh Laurie Feinman, um who's a clinical nurse specialist at U CS F. Um who uh has been there for 30 32 years. Yeah. Ok. Thank you. In 2018, we began to build our neonatal cardiac neurodevelopmental support program. And we decided to call it the grand program, which is an acronym for Growth and Neuro Development. In addition to the four of us that we have these two really important leaders. Um I know you saw the picture of Doctor Reddy beforehand, but he's our primary neonatal cardiac surgeon and he's pictured here with a pre term infant. This is like a 1996 97 who had hypoplastic left heart syndrome and this is the day of her discharge after her nor procedure. And then Doctor Martina Drewer, who is board certified in pediatric critical care and neonatology. So she brings a wealth of experience and knowledge to our group as well. She's also the medical director of our neonatal area of our unit. But before us, there were many others that were doing this work and we really rallied behind these people. I just wanna point out these two papers that I saw um back in 2018 and really realized that we had a void in our unit. Uh The first one was Amy Sante. And many of you have heard her speak um at this meeting, but she published this paper in 2016. Um really talking about developmental care rounds and the neonatal intensive care unit with the purpose of identifying the neuro developmental needs and the role of the interdisciplinary team to really try to meet those needs in a unique way. She specifically spells out the role of the clinical learn specials. So I really felt like um this was uh I had a responsibility to leadership for this program. And then in 2017, Samantha Butler from Boston published this paper filling a significant gap in the cardiac IC U. And I'm so grateful that she titled that because I saw this and I thought, wow, I read the paper and I realized, yes, we have a gap and there's a need and we need to really move on this action. So for our grant program, we took the elements that we had in the, in the literature and specifically the NC um guidelines that Samantha Butler outlines in her paper. And we put those elements of care into four bundles. The care bundle primarily in the beginning was focused around um appropriate positioning, our patients, even the patients that come out from the operating room with open chest and on ECLS um to be able to put them in a developmental positioner and provide some alignment of their body and their hands and their feet to their core. Um And also just like controlling the environment with noise reduction and cycled lighting. In the parent bundle, we were really focused in the beginning on parent participation. We still are. This is one of the most important bundles that we have the role of the parents to provide comfort to their baby with, with reading, to them and singing to them, using their voice, using their hands to comfort ways that they would normally think about doing it at home. But applying this in the critically ill baby and then also if the moms intended to breastfeed to make sure that very early on, we provided lactation support for them. The feeding bundle in the beginning, we really focused on oral care with breast milk um to uh really expose a baby to the classroom that the mom had um with the first pumping and then we moved on to our preoperative and postoperative feeding guidelines. The comfort bundle is primarily focused around non pharmacologic comfort measurements with infant massage and acu therapy. And we also put together a pretty strict protocol around the appropriate use of oral sucrose for painful procedures. Once we had those like the guidelines in place, we wanted to the strategy we wanted to implement. We really thought about what's the environment we want to provide this care in. And at the time, we had an 18 bed Cardiac Ic U and the neonates were scattered around throughout those 18 beds. And we really thought that the the best way for us to implement this care would be to have these babies cohort within our larger cardiac intensive care unit. And there was one area that was the furthest away from where the providers have their work room and the nurses have their charge nurse station and where the people gather and all the activity is this was the area that was furthest away from, there was eight consecutive beds. And we decided this is where we could really control the environment with noise reduction and cycle lighting. We were able to get some funding to decorate the area that when we use the San Francisco's theme with the notorious fog and the, the Golden Gate Bridge and the tower. But you can walk into this area of the IC U. And you realize, ok, this is where babies are cared for. We call this area the nest, which is an acronym for nurturing environment for small hearts. The other thing we did is we uh really sequestered eight nursing grand champions from the C IC originally. And these, so there were two nurse champions per bundle of care. And these nurses were had experience in neonatal care or real passionate about the, the field ahead of us and they built our guidelines for each one of the care bundles. They were responsible for teaching all of the nurses uh developing the documents that were good resources for the nurses. And to this day, they still have 15 minutes in every n staff meeting to provide grand updates. In addition on Mondays on Mondays uh for the C IC U, there's uh one grand champion that's works for eight hours on her grand projects. In addition to the C I, the CTC, our transitional carrier has a, a nurse who works for four hours. So together they work on our uh ongoing grand projects and provide just in time teaching. They round every week and they talk to families and and nurses and provide support. They also put together this really nice parent infant holding guideline and we always held, you know, always had parents hold infants, but this provided some real structure for the nurses to develop, to really identify criteria for holding, to kind of push the envelope a little bit to hold more critically ill patients. Um And one of the nurses is an audience today. She spearheaded this project and was actually able to show that with the development of this guideline, she was able to increase the episodes of holding from the pre implementation to post implementation. And we also put together this holding tree and this is a place where in in the nest where parents can put a sticker up on a branch and they can put their babies name or initials and the date of their first post operative holding episode, just something for us to celebrate with them. Our families, again, the core of this project, um the most important element, we put together this accordion pamphlet for them. So when they're admitted to the C IC U, we give them information that talks about the nest, the environment that we're trying to create for the benefit of their child. And then it goes through each one of the bundles of care, the elements that we want to, the care we want to provide and their role in the provision of that care. Every Monday at one o'clock, we have grand rounds. Uh We have a large interdisciplinary team that rounds, sometimes it's smaller than this. Uh We really encourage the families to participate in these rounds. They know that we're coming between one and two to round. Uh We encourage them to be present and join us. If they're in the room with their baby, comforting them or sitting next to them or holding them, then we take a small portion of the group and we move into the room and we round with them there. This uh the grant rounds are led by the RN champion. Um he or she has rounded earlier and then in rounds presents the patient talks about the elements that carry that are well implemented and then identifies a few challenging elements for this particular child, child. For example, feeding challenges, oral oral intake issues, um vomiting, feeding intolerance, agitation, drug withdrawal. And then as together as a team, we come up with a plan to, to, to support this baby through this process. If parents can't be present, they're, then we, we work really hard with our child life therapy group to obtain voice recordings of the family. So we can use that to play for the child when they're not there. Our integrated medicine team is a really important uh part of our interdisciplinary group and their primary uh provision of care is around in a massage and acu therapy. The in a massage is for any kind of feeding challenges again, for agitation. And they're very good about doing the massage, finding the infant response, deciding what's best for this baby and then teaching the family how to do the massage in order to be able to comfort the baby. And then also the acu therapy, which is primarily finger pressure and sometimes the metal instruments that they use to provide pressure. I think our future is pretty bright. Actually, fortunately, we have obtained some funding through a donation for the neonatal cardiovascular Center of Excellence. And so we really hope to use that to support more grant positions. We need help around uh psychologists, we need physical therapy, occupational therapy dedicated to this program, lactation specialists. Uh We also really want to obtain, put some structure to obtain some quality outcome data. We've never really been able to do that. We want to be able to contribute to the science as much as we can. And then most importantly, I think trying to implement this program from the time of diagnosis. So move that forward to fetal diagnosis, definitely newborn diagnosis to let parents know about the grant program that the goals we're trying to achieve and then to carry that out to the day of discharge. Thank you. Thank you, Laurie. I cannot tell you what a wonderful resource uh Laurie has been over the now decades. I don't want to make her seem old. She's not. But uh but uh if you can find a clinical nurse specialist with this amount of experience, expertise in uh in, in caring for cardiac babies, um grab her while you can, but you can't have this one keeping her. Um I think that that's the end of our uh of our program and the end of our time here, there's a little bit of food left in the back. So grab something on your way out and thank you so much for, for coming and uh and celebrating the life of Doctor Rudolph and his legacy with us. Uh enjoy the rest of your World Congress. Interesting know.
