Neurocognitive Monitoring and Care During Pediatric Cardiopulmonary Bypass — Current and Future Directions

Jennifer Lee,Kenneth Brady,R Easley

doi:10.2174/157340308784245766

Abstract

Neurologic injury in patients with congenital heart disease remains an important source of morbidity and mortality. Advances in surgical repair and perioperative management have resulted in longer life expectancies for these patients. Current practice and research must focus on identifying treatable risk factors for neurocognitive dysfunction, advancing methods for perioperative neuromonitoring, and refining treatment and care of the congenital heart patient with potential neurologic injury. Techniques for neuromonitoring and future directions will be discussed.

Highlights

Advances in pediatric cardiac surgery have significantly improved morbidity and mortality for children with congenital heart disease (CHD), bringing new hope to patients and their families, but children who survive the perioperative period still face developmental challenges as they grow older
Many pediatric cardiac surgeries require cardiopulmonary bypass (CPB), which greatly increases the risk of brain injury
Low bypass flow rates were significantly associated with postoperative brain injury, and four of these six patients received retrograde cerebral perfusion

Summary

INTRODUCTION

Advances in pediatric cardiac surgery have significantly improved morbidity and mortality for children with congenital heart disease (CHD), bringing new hope to patients and their families, but children who survive the perioperative period still face developmental challenges as they grow older. Many pediatric cardiac surgeries require cardiopulmonary bypass (CPB), which greatly increases the risk of brain injury. Maintaining cerebral autoregulation during the bypass period is crucial in preventing brain injury during cardiac surgery. CPP, cerebral perfusion pressure; CBF, cerebral blood flow; CPB, cardiopulmonary bypass; BBB, blood-brain barrier; ICP, intracranial pressure; DHCA, deep hypothermic circulatory arrest; ACT, activated clotting time; CHD, congenital heart disease. Increased cerebrovascular resistance and altered tissue microcirculation postbypass decrease oxygen delivery to the brain [20,21,22] These factors, combined with impaired cerebral pressure autoregulation from bypass, increase the risk of brain ischemia, during hypotension. Factors associated with postoperative brain injury included lower bypass flow rates, worse intraoperative metabolic acidosis, retrograde cerebral perfusion, and low MAP on the first postoperative day [10].

Limitations

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CONCLUSION