Abstract
Objectives: 1 Measure serial serum intestinal fatty acid binding protein levels in infants undergoing cardiac surgery with cardiopulmonary bypass to evaluate for evidence of early post-operative enterocyte injury. 2 Determine the association between immediate post-operative circulating intestinal fatty acid binding protein levels and subsequent development of necrotizing enterocolitis.Design: Observational cohort study. Intestinal fatty acid binding protein was measured pre-operatively, at rewarming, and at 6 and 24 h post-operatively. Percent of goal enteral kilocalories on post-operative day 5 and episodes of necrotizing enterocolitis were determined. Multivariable analysis assessed for factors independently associated with clinical feeding outcomes and suspected/definite necrotizing enterocolitis.Setting: Quaternary free-standing children's hospital pediatric cardiac intensive care unit.Patients: 103 infants <120 days of age undergoing cardiothoracic surgery with cardiopulmonary bypass.Interventions: None.Results: Median pre-operative intestinal fatty acid binding protein level was 3.93 ng/ml (range 0.24–51.32). Intestinal fatty acid binding protein levels rose significantly at rewarming (6.35 ng/ml; range 0.54–56.97; p = 0.008), continued to rise slightly by 6 h (6.57 ng/ml; range 0.75–112.04; p = 0.016), then decreased by 24 h (2.79 ng/ml; range 0.03–81.74; p < 0.0001). Sixteen subjects (15.7%) developed modified Bell criteria Stage 1 necrotizing enterocolitis and 9 subjects (8.8%) developed Stage 2 necrotizing enterocolitis. Infants who developed necrotizing enterocolitis demonstrated a significantly higher distribution of intestinal fatty acid binding protein levels at both 6 h (p = 0.005) and 24 h (p = 0.005) post-operatively. On multivariable analysis, intestinal fatty acid binding protein was not associated with percentage of goal enteral kilocalories delivered on post-operative day 5. Higher intestinal fatty acid binding protein was independently associated with subsequent development of suspected/definite necrotizing enterocolitis (4% increase in odds of developing necrotizing enterocolitis for each unit increase in intestinal fatty acid binding protein; p = 0.0015).Conclusions: Intestinal fatty acid binding protein levels rise following infant cardiopulmonary bypass, indicating early post-operative enterocyte injury. Intestinal fatty acid binding protein was not associated with percent of goal enteral nutrition achieved on post-operative day 5, likely due to protocolized feeding advancement based on clinically observable factors. Higher intestinal fatty acid binding protein at 6 h post-operatively was independently associated with subsequent development of necrotizing enterocolitis and may help identify patients at risk for this important complication.
Highlights
Infants undergoing surgery for congenital heart disease (CHD) with cardiopulmonary bypass (CPB) are at high risk for intestinal injury, both during the surgery itself and subsequently from ongoing post-operative low cardiac output [1, 2]
Much of the recent research involving intestinal fatty acid-binding protein (IFABP) has been as a predictor of necrotizing enterocolitis (NEC) in the neonatal population [23,24,25], but it has been utilized as an indicator of intestinal injury across many different contexts including cardiac surgery in both adults and children [3, 26,27,28,29,30]
Pre-operative clinical characteristics found to be significantly associated with higher IFABP include older age, higher weight, prior initiation of pre-operative enteral nutrition, and lack of prostaglandin use
Summary
Infants undergoing surgery for congenital heart disease (CHD) with cardiopulmonary bypass (CPB) are at high risk for intestinal injury, both during the surgery itself and subsequently from ongoing post-operative low cardiac output [1, 2]. This intestinal injury can lead to major postoperative complications including intestinal barrier dysfunction, dysmotility, post-operative feeding intolerance, and post-operative necrotizing enterocolitis (NEC) [3,4,5,6,7,8,9,10,11,12,13]. Associations between IFABP levels and feeding tolerance or clinical suspicion of NEC have not been assessed in this highrisk population
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