Children Undergoing Heart Surgery Research Articles

Platelet reactivity in young children undergoing congenital heart disease surgery: a NITRIC randomized clinical trial substudy

IntroductionThe international NITRIC trial studied the hypothesis that nitric oxide (NO) applied into the cardiopulmonary bypass (CPB) oxygenator in infants would improve recovery after heart surgery. In a substudy, we evaluated the effect of NO applied into the CPB oxygenator on the (re)activity of platelets measured as fibrinogen binding (platelet aggregation) and P-selectin expression (platelet degranulation) in young children.MethodsPlatelet activity (without agonist exposure) and reactivity (after stimulation by an agonist) was studied in a single center substudy of the NITRIC trial, a multicenter, randomized trial that studied administration of 20 parts per million (ppm) NO during CPB in children younger than 2 years. Blood was collected at 4 time points (T1- T4); before CPB, after CPB start, before and after weaning. Flow cytometry-based platelet activity and reactivity in the presence of 5 agonists was tested. Differences on P-selectin expression and fibrinogen binding (median fluorescence intensity (MFI)) were analyzed with mixed effect modelling (MEM).ResultsBlood samples were obtained in 22 patients allocated to NO and 20 controls. Platelet counts dropped after T1 due to the hemodilution of blood in all patients (p < 0.001). Beta coefficients for NO allocation derived from the MEM models on fibrinogen binding and P-selectin expression were small (standardized beta coefficients on fibrinogen binding were 0.07[0.03, 0.11] and on P-selectin expression 0.05[0.03, 0.08]) and non-significant. CPB duration did not affect platelet reactivity (standardized beta coefficients 0.09[0.02, 0.12] with p > 0.27) in any of the MEMs.Conclusion20 ppm NO administration in the sweep gas of the CPB oxygenator did not affect platelet reactivity in young children undergoing heart surgery. Interestingly, duration of CPB exposure also did not have an effect on platelet (re)activity.Trial registrationANZCTR, ACTRN12617000821392. Registered 5 June 2017, https://anzctr.org.au/

A single-center, retrospective analysis to compare measurement of fibrinogen using the TEG6 analyzer to the Clauss measurement in children undergoing heart surgery.

Newer generation viscoelastic tests, TEG6s, offer point-of-care hemostatic therapy in adult patients. However, their efficacy in estimating fibrinogen levels in pediatric patients undergoing cardiac surgery is not well established. This study evaluates TEG6s for estimating fibrinogen levels in pediatric cardiac surgery patients and its predictive capability for post-bypass hypofibrinogenemia. A single-center, retrospective study on pediatric patients (under 18 years) who underwent cardiac surgery with cardiopulmonary bypass from August 2020 and November 2022. Blood samples for estimated whole blood functional fibrinogen level via TEG6s (Haemonetics Inc.) and concurrent laboratory-measured plasma fibrinogen via von Clauss assay were collected at pre- and post-cardiopulmonary bypass. Paired data for TEG6s estimated functional fibrinogen levels and plasma fibrinogen were analyzed for 432 pediatric patients pre-bypass. It was observed that functional fibrinogen consistently overestimated plasma fibrinogen across all age groups with a mean difference of 138 mg/dL (95% confidence interval [CI]: 128-149 mg/dL). This positive bias in the pre-bypass data was confirmed by Bland-Altman analysis. Post-bypass, functional fibrinogen estimates were comparable to plasma fibrinogen in all patient groups with a mean difference of -6 mg/dL (95% CI: -20-8 mg/dL) except for neonates, where functional fibrinogen levels underestimated plasma fibrinogen with a mean difference of -38 mg/dL (95% CI: -64 to -12 mg/dL). The predictive accuracy of functional fibrinogen for detecting post-bypass hypofibrinogenemia (plasma fibrinogen ≤250 mg/dL) demonstrated overall fair accuracy in all patients, indicated by an area under the curve of 0.73 (95% CI: 0.65-0.80) and good accuracy among infants, with an area under the curve of 0.80 (95% CI: 0.70-0.90). Similar performance was observed in predicting critical post-bypass hypofibrinogenemia (plasma fibrinogen ≤200 mg/dL). Based on these analyses, optimal cutoffs for predicting post-bypass hypofibrinogenemia were established as a functional fibrinogen level ≤270 mg/dL and MAFF ≤15 mm. This study demonstrates that whole blood functional fibrinogen, as estimated by TEG6s, tends to overestimate baseline plasma fibrinogen levels in pediatric age groups but aligns more accurately post-cardiopulmonary bypass, particularly in neonates and infants, suggesting its potential as a point-of-care tool in pediatric cardiac surgery. However, the variability in TEG6s performance before and after bypass highlights the need for careful interpretation of its results in clinical decision-making. Despite its contributions to understanding TEG6s in pediatric cardiac surgery, the study's design and inherent biases warrant cautious application of these findings in clinical settings.

Peripheral Regional Anesthetic Techniques in Cardiac Surgery: A Systematic Review and Meta-Analysis

Objective(s)Aim of this systematic review was to investigate postoperative pain outcomes and adverse events following peripheral regional anesthesia (PRA) compared to no regional anesthesia (RA), placebo or neuraxial anesthesia in children and adults undergoing cardiac surgery. DesignSystematic review and meta-analysis with assessment of the risk of bias (Cochrane RoB 1) and certainty of evidence (GRADE). SettingRandomized controlled trials ParticipantsAdults and children undergoing heart surgery InterventionsAny kind of PRA compared to no RA or placebo or neuraxial anesthesia Measurements and Main resultsIn total 33 RCTs (2044 patients) – 24 of these had a high risk of bias and 28 were performed in adults - were included. PRA compared to no RA may reduce pain intensity at rest 24 h after surgery (MD -0.81 points, 95% CI -1.51 to -0.10; I2 = 92%; very low certainty evidence). PRA compared to placebo may reduce pain intensity at rest (MD -1.36 points, 95% CI -1.59 to -1.13; I2 = 54%; very low certainty evidence) and during movement (MD -1.00 points, 95% CI -1.34 to -0.67; I² = 72%; very low certainty evidence) 24 h after surgery. No data following pediatric cardiac surgery could be meta-analysed due to the low number of included trials. ConclusionsPRA compared to no RA or placebo may reduce pain intensity at rest and during movement. However, these results should be interpreted cautiously, because the certainty of evidence is only very low. Protocol registrationCRD42021223636

Aerosolized lidocaine to reduce tracheal suction-associated pain after pediatric congenital heart surgery: A randomized, double-blind, placebo-controlled trial

BackgroundIn children undergoing heart surgery for congenital heart disease (CHD), postoperative pain is associated with changes in the respiratory system that can lead to complicated courses and poor outcomes. Respiratory therapy (RT) can restore respiratory function through manual techniques and tracheal suction (TS). However, TS itself can cause pain, leading to hemodynamic and respiratory manifestations, such as tachycardia, hyper- or hypotension, tachypnea, increased work-of-breathing, patient-ventilator asynchrony, among others. ObjectivesThe aim of this study was to investigate whether RT/TS increases pain and whether inhaled lidocaine can attenuate pain increase in infants and children undergoing surgery for CHD. MethodsDouble-blind, randomized, placebo-controlled trial at a pediatric intensive care unit in a Brazilian tertiary-care university hospital. Patients <18 years submitted to open-heart surgery for CHD were included and randomized to receive either aerosolized lidocaine (1 mg/kg) or placebo before RT/TS. Pain was assessed by the Face, Legs, Activity, Cry, Consolability pain scale – revised (FLACC-R), along with hemodynamic and ventilatory parameters, before and 10 min after RT/TS start on postoperative days 1, 3, and 7 given they were on mechanical ventilation. Results119 patients were included. RT/TS induced minor changes in pain, which were not attenuated by lidocaine (confirmed in multivariate analysis). RT/TS also caused minor, clinically not relevant effects in hemodynamic and ventilatory parameters, which were also not modified by lidocaine. ConclusionRespiratory therapy with tracheal suction did not increase postoperative pain in ventilated children after congenital heart surgery until the 7th day, nor did aerosolized lidocaine exhibit any clinically significant effect on pain or other hemodynamic or ventilatory parameters.Registered at REBEC: RBR-10vtd55m.

Pediatric Animal Model of Extracorporeal Cardiopulmonary Resuscitation after Prolonged Circulatory Arrest.

Congenital heart disease (CHD) is the most prevalent congenital malformation, with about one million births impacted worldwide per year. Comprehensive investigation of this disease requires appropriate and validated animal models. Piglets are commonly used for translational research due to their analogous anatomy and physiology. This work aimed to describe and validate a neonatal piglet model of cardiopulmonary bypass (CPB) with circulatory and cardiac arrest (CA) as a tool for studying severe brain damage and other complications of cardiac surgery. In addition to including a list of materials, this work provides a roadmap for other investigators to plan and execute this protocol. After experienced practitioners performed several trials, the representative results of the model demonstrated a 92% success rate, with failures attributed to small piglet size and variant vessel anatomy. Furthermore, the model allowed practitioners to select from a wide variety of experimental conditions, including varying times in CA, temperature alterations, and pharmacologic interventions. In summary, this method uses materials readily available in most hospital settings, is reliable and reproducible, and can be widely employed to enhance translational research in children undergoing heart surgery.

ORCHID (Outcome Registry for CHIldren with severe congenital heart Disease) a Swiss, nationwide, prospective, population-based, neurodevelopmental paediatric patient registry: framework, regulations and implementation.

Congenital heart disease (CHD) is the most frequent birth defect. As survival has significantly improved, attention has turned to neurodevelopmental outcomes of children undergoing heart surgery in early infancy. Since multiple risk factors contribute to neurodevelopmental alterations, a nationwide registry collecting data on medical characteristics, interventions, clinical course and neurodevelopment until school-age is needed to improve the quality of management, identify risk- and protective factors affecting neurodevelopment, and facilitate multicentre trials. The Swiss Outcome Registry for CHIldren with severe congenital heart Disease (ORCHID) is a nationwide, prospective, population-based patient registry developed (1) to collect baseline characteristics and clinical data of CHD patients operated with bypass-surgery or hybrid procedures in the first 6 weeks of life in Switzerland, (2) to monitor long-term neurodevelopment, and (3) to relate clinical characteristics and neurodevelopment to identify risk and protective factors in these children. This registry started data collection relating to pregnancy, birth, preoperative course, catheter-based and surgical treatment, postoperative course and reinterventions in 2019. The primary outcome includes standardised neurodevelopmental assessments at 9 to 12 months, 18 to 24 months and 5.5 to 6 years. We expect to include 80 to 100 children per year. Correlation and regression analyses will be used to investigate risk- and protective factors influencing neurodevelopment. Swiss ORCHID received support by the Accentus Charitable Foundation, the Anna Mueller Grocholoski Stiftung, the Swiss Society of Paediatric Cardiology, the Verein Kinderherzforschung, and the Corelina - Stiftung für das Kinderherz, and was approved by the cantonal ethics committees. Findings will be presented at national and international scientific meetings, and published in peer-reviewed journals. Results will also be shared with patient organizations, primary health care providers, and public health stakeholders to ensure a widespread dissemination of the results.

Effect of Nitric Oxide via Cardiopulmonary Bypass on Ventilator-Free Days in Young Children Undergoing Congenital Heart Disease Surgery

In children undergoing heart surgery, nitric oxide administered into the gas flow of the cardiopulmonary bypass oxygenator may reduce postoperative low cardiac output syndrome, leading to improved recovery and shorter duration of respiratory support. It remains uncertain whether nitric oxide administered into the cardiopulmonary bypass oxygenator improves ventilator-free days (days alive and free from mechanical ventilation). To determine the effect of nitric oxide applied into the cardiopulmonary bypass oxygenator vs standard care on ventilator-free days in children undergoing surgery for congenital heart disease. Double-blind, multicenter, randomized clinical trial in 6 pediatric cardiac surgical centers in Australia, New Zealand, and the Netherlands. A total of 1371 children younger than 2 years undergoing congenital heart surgery were randomized between July 2017 and April 2021, with 28-day follow-up of the last participant completed on May 24, 2021. Patients were assigned to receive nitric oxide at 20 ppm delivered into the cardiopulmonary bypass oxygenator (n = 679) or standard care cardiopulmonary bypass without nitric oxide (n = 685). The primary end point was the number of ventilator-free days from commencement of bypass until day 28. There were 4 secondary end points including a composite of low cardiac output syndrome, extracorporeal life support, or death; length of stay in the intensive care unit; length of stay in the hospital; and postoperative troponin levels. Among 1371 patients who were randomized (mean [SD] age, 21.2 [23.5] weeks; 587 girls [42.8%]), 1364 (99.5%) completed the trial. The number of ventilator-free days did not differ significantly between the nitric oxide and standard care groups, with a median of 26.6 days (IQR, 24.4 to 27.4) vs 26.4 days (IQR, 24.0 to 27.2), respectively, for an absolute difference of -0.01 days (95% CI, -0.25 to 0.22; P = .92). A total of 22.5% of the nitric oxide group and 20.9% of the standard care group developed low cardiac output syndrome within 48 hours, needed extracorporeal support within 48 hours, or died by day 28, for an adjusted odds ratio of 1.12 (95% CI, 0.85 to 1.47). Other secondary outcomes were not significantly different between the groups. In children younger than 2 years undergoing cardiopulmonary bypass surgery for congenital heart disease, the use of nitric oxide via cardiopulmonary bypass did not significantly affect the number of ventilator-free days. These findings do not support the use of nitric oxide delivered into the cardiopulmonary bypass oxygenator during heart surgery. anzctr.org.au Identifier: ACTRN12617000821392.

Effect of Family-Centered Care on Mothers' Information Needs, Anxiety and Depression Level Regarding Care for their Children Undergoing Heart Surgery

Effect of Family-Centered Care on Mothers' Information Needs, Anxiety and Depression Level Regarding Care for their Children Undergoing Heart Surgery

Using Air Cushion in the Prevention of Occipital Pressure Ulcer in Children Undergoing Heart Surgery

Background &amp; Aims: Congenital heart disease is one of the main causes of death in their first year of life. One of the most significant complications of surgery in these patients is pressure ulcers. The aim of this study was to determine the effect of using air cushion in the prevention of occipital pressure ulcer in children undergoing heart surgery. Materials &amp; Methods: The present study was a randomized clinical trial and 135 children undergoing open heart surgery aged 0 to 12 years referred to two cardiac centers in Tabriz and Tehran. They were randomly assigned to the intervention and control groups by continuous sampling during one year (September 2016- September 2017). The group of intervention used air cushions that has an air inlet and outlet pump and is filled and emptied by a pump alternately and creates 3 to 4 cm waves. This air cushion with dimensions of 30 to 40 cm waterproof and anti-allergy air cushion covered with a cotton cover. Data collection tools included: National Pressure Ulcer Advisor Panel and Braden Q. Chi-square, Fisher's exact test, independent t-test, Mann-Whitney and analysis of covariance were used to achieve the goals. Results: The incidence of occipital pressure ulcer in the control group after surgery was 38.7%, the first day after surgery was 71% and the second day after surgery was 67.7%. However, in the intervention group no occipital pressure ulcer was observed in all periods after surgery. There was no significant difference in the scores of pressure ulcers in the preoperative times between the intervention and control groups (P&lt;0.05), but after operation and the second day of surgery, the scores of pressure ulcers in the intervention group were significantly higher than the control group (P=0.002). This means that the pressure ulcer scores in the intervention group were better than the control group. Conclusion: The use of air cushion appropriate to the size and weight of children is a suitable equipment to prevent occipital pressure ulcer in children undergoing open heart surgery.

Evolving Cost-Quality Relationship in Pediatric Heart Surgery

BackgroundFor the more than 40,000 children in the United States undergoing congenital heart surgery annually, the relationship between hospital quality and costs remains unclear. Prior studies report conflicting results and clinical outcomes have continued to improve over time. We examined a large contemporary cohort, aiming to better inform ongoing initiatives seeking to optimize health care value in this population. MethodsClinical information (The Society of Thoracic Surgeons Congenital Database) was merged with standardized cost data (Pediatric Health Information Systems) for children undergoing heart surgery from 2010 to 2015. In-hospital cost variability was analyzed using Bayesian hierarchical models adjusted for case-mix. Quality metrics examined included in-hospital mortality, postoperative complications, postoperative length of stay (PLOS), and a composite. ResultsOverall, 32 hospitals (n = 45,315 patients) were included. Median adjusted cost per case varied across hospitals from $67,700 to $51,200 in the high vs low cost tertile (ratio 1.32; 95% credible interval, 1.29 to 1.35), and all quality metrics also varied across hospitals. Across cost tertiles, there were no significant differences in the quality metrics examined, with the exception of PLOS. The PLOS findings were driven by high-risk The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery categories 4 and 5 cases (adjusted median length of stay 16.8 vs 14.9 days in high vs low cost tertile [ratio 1.13, 1.05 to 1.24]), and intensive care unit PLOS. ConclusionsContemporary congenital heart surgery costs vary across hospitals but were not associated with most quality metrics examined, highlighting that performance in one area does not necessarily convey to others. Cost variability was associated with PLOS, particularly related to intensive care unit PLOS and high-risk cases. Care processes influencing PLOS may provide targets for value-based initiatives in this population.

Effect of Family-Centered Care on Maternal Coping and Care Participation for their Children with Congenital Heart Diseases

Contents: Families of children with congenital heart disease face frequent healthcare encounters due to their child's care trajectory. With an emphasis on assuring caring in healthcare, it is necessary to understand parents’ perceptions of healthcare providers’ actions when their child undergoes heart surgery.&#x0D; Aim: This study aimed to evaluate the effect of family-centered care intervention on maternal coping and participation in care for their children with congenital heart diseases.&#x0D; Methods: A quasi-experimental design was used. The study was carried out at the pediatric inpatient department in Cardiovascular Hospital, affiliated to Ain Shams University Hospitals. A purposive sample of 50 children undergoing heart surgery and their accompanying mothers. The study was used a structured interview questionnaire, the family-centered care scale, the index of mothers' participation, mothers’ practice observational checklists, and the coping process scale to collect the study’s data.&#x0D; Results: The study reveals a statistically significant difference in the mothers' total coping pattern after family-centered care intervention compared to before intervention at p=0.000. A statistically significant difference was also revealed regarding the total mothers' participation in the care of their children with congenital heart disease at p=0.000. There was a strong positive correlation between total mothers' coping patterns, participation, and mothers' total actual practices regarding their children's care suffering from congenital heart diseases after the intervention.&#x0D; Conclusion: The family-centered care intervention effectively improved mothers' coping patterns and participation in care for their children with congenital heart diseases. Emphasizing the importance of family (usually the mother) participation in care for their children with congenital heart diseases during hospitalization for heart surgery. Designing and carrying out educational programs for pediatric nurses to promote family-centered care in clinical practice.

Vancomycin concentrations during cardiopulmonary bypass in pediatric cardiac surgery: a prospective study.

Few data are available regarding intraoperative plasma concentrations of vancomycin administered as prophylaxis in pediatric cardiac surgery. The aims of this study were to investigate during pediatric cardiac surgery with cardiopulmonary bypass(CPB) the attainment of the area-under-the-curve of the vancomycin serum concentrations versus time over surgery to minimum inhibitory concentration ratio(AUCintra/MIC) of 400 (mg × h)/l and/or a target concentration of 15-20 mg/l. In a prospective study, 40 patients divided into four subgroups (neonates, infants, children <10 years-old, ⩾10 years-old) undergoing cardiac surgery with cardiopulmonary bypass (CPB) were enrolled. A slow vancomycin bolus of 20 mg/kg, up to a maximum dose of 1000 mg was administered before skin incision and a further dose of 10 mg/kg (up to 500 mg) at CPB start. Vancomycin samples were collected intraoperatively at four time points. The median (interquartile range) age was 241.5 days (47-3898) and the median weight was 7.1 kg (3.1-37). The median AUCintra/MIC was 254.73 (165.89-508.06). In 11 patients the AUCintra/MIC target was not reached. Neonates displayed the lowest AUCintra/MIC values, and these were significantly lower than those of children ⩾10 years old (p = 0.02). Vancomycin concentrations were above the maximal target of 20 mg/l in 82.5% and 80% of patients at surgery and CPB start, respectively. At CPB and surgery end, 42.5% of patients showed vancomycin concentrations above 20 mg/l and 42.5% below 15 mg/l. Patients⩾10 years old showed the highest peak values whereas neonates were those with the lowest troughs. AUCintra/MIC correlated with age(r:0.36, p = 0.02), weight(r:0.35, p = 0.03), intraoperative protein value(r:0.40, p = 0.01), CPB priming volume/kg(r:-0.33, p = 0.04), CPB duration(r:0.36, p = 0.02) and vancomycin troughs(r:0.35, p = 0.04). An AUCintra/MIC ⩾400 target was not reached in one-quarter of children undergoing heart surgery. Vancomycin peaked before the start of surgery and neonates were those with the lowest troughs. Vancomycin concentrations are affected by CPB hemodilution and by patients' age and weight.

Understanding parents’ decision-making on participation in clinical trials in children’s heart surgery: a qualitative study

ObjectivesFew children undergoing heart surgery are recruited to clinical trials and little is known about the views and attitudes of parents towards trials. This study explored parents’ perspectives on decision-making...

Living with the Memories—Parents’ Experiences of Their Newborn Child Undergoing Heart Surgery Abroad: A Qualitative Study

Parents of children with a congenital heart defect needing complex heart surgery are at high risk of developing health problems. One can assume that parents whose child undergoes heart surgery abroad will undoubtably face added and unique stressors and health vulnerabilities. The aim of this qualitative study was to explore the transition experiences of parents of children who underwent a complex heart surgery abroad as newborns 1–5 years ago. The qualitative content analysis methodology by Graneheim and Lundman was used. A purposive sample of twelve parents, whose child had undergone a heart surgery abroad, participated in face-to-face, semi-structured interviews. Interviews were transcribed and analyzed using inductive qualitative content analysis. The overarching theme of “living with the memories” emerged from parents’ experiences, emphasizing the long-lasting impact this stressful event had on their lives. These experiences were characterized by four main categories: (1) being in an unknown situation; (2) feeling connected; (3) wishing to be accepted; and (4) finding closure. The findings show that the transition of having a newborn child undergo heart surgery abroad superimposed on the expected parenthood. That parents need to feel connected and included as legitimate clients was highlighted in their stories of experienced vulnerabilities. The results highlight the need for interdisciplinary teams to support these vulnerable families, particularly with follow-up care.

Indexing haemodynamic variables in young children.

BackgroundHaemodynamic studies in children are rare and most studies have included few subjects in the youngest age group. Haemodynamic variables need to be indexed to establish a reference of normality that is valid in all populations. The traditional way to index haemodynamic variables with body surface area (BSA) is complicated in young children due to its non‐linear relationship with body weight (BW). We examined several haemodynamic variables in children by indexing them with BSA and BW.MethodsA single‐centre, observational cohort study comparing non‐indexed and indexed haemodynamic variables in children undergoing heart surgery (divided into three weight groups: 1‐5 kg, >5‐10 kg and >10‐15 kg).ResultsA total of 68 children were included in this study, mean age 11.1 months ± 11.1 month (range 0 to 43 months). All haemodynamic variables, cardiac output (CO), stroke volume (SV), total end‐diastolic volume (TEDV), central blood volume (CBV) and active circulation volume (ACV), increased with weight without indexing (P < .05). Indexing variables with BW produced a more linear relationship for all haemodynamic variables between weight groups than BSA. The mean BSA‐indexed haemodynamic values were CIBSA 3.5 ± 1.1 L/min/m2 and SVIBSA 27.3 ± 8.9 ml/min/m2. The mean BW‐indexed haemodynamic values were CIBW 180 ± 50 ml/min/kg and SVIBW 1.34 ± 0.38 ml/kg. Blood volume variables indexed with BW were TEDVBW 12.0 ± 2.8 ml/kg, CBVBW 21.3 ± 6.6 ml/kg and ACVBW 70.3 ± 15.2 ml/kg.ConclusionsIndexing haemodynamic variables with BW produces a more appropriate body size‐independent scale in young children than BSA.Summary statementIn this study, we studied indexing of haemodynamic variables and estimation of blood volumes in young children undergoing corrective heart surgery using an indicator dilution technology.

The Peacock study: feasibility of the dynamic characterisation of the paediatric hypothalamic-pituitary-adrenal function during and after cardiac surgery

BackgroundCortisol is the main stress hormone mobilised during surgery to establish homeostasis. Our current understanding of the hypothalamic-pituitary-adrenal axis physiology in children undergoing cardiopulmonary bypass is very limited due to: (1) very few cortisol time point measurements over long periods (2) difficulties of sampling in low weight babies and (3) the concomitant use of glucocorticoids at anaesthesia induction. This lack of understanding is reflected in a lack of consensus on the utility of glucocorticoids perioperatively in cardiac surgery with the use of cardiopulmonary bypass.MethodsThe Peacock Study is a prospective, two-centre, observational cohort study of 78 children (undergoing cardiopulmonary bypass procedures and non-surgical procedures - split by age/cyanosis) that aims to characterise in detail the hypothalamic-pituitary-adrenal axis physiology of children using the stress model of paediatric cardiac surgery. Also, we aim to correlate cortisol profiles with clinical outcome data. We herein describe the main study design and report the full cortisol profile of one child undergoing heart surgery, thus proving the feasibility of the method.ResultsWe used an automated, 24-h tissue microdialysis system to measure cortisol and cortisone, every 20 min. We herein report one cortisol profile of a child undergoing heart surgery. Besides, we measured serum cortisol and adrenocorticotrophic hormone at seven-time points for correlation. Tissue concentrations of cortisol increased markedly several hours after the end of surgery. We also noted an increase in the tissue cortisol/cortisone ratio during this response.ConclusionWe report for the first time, the use of an automated microdialysis sampling system to evaluate the paediatric adrenal response in children. Changes in cortisol and cortisone could be measured, and the concentration of cortisol in the tissues increased after the end of cardiac surgery. The method has wide application to measure other hormones dynamically and frequently without the limitation of the circulating blood volume. The data from the main study will clarify how these cortisol profiles vary with age, pathology, type of procedure and correlation to clinical outcomes.Trial registrationISCRTN registry, number: 982586.

Six commonly used empirical body surface area formulas disagreed in young children undergoing corrective heart surgery.

Formulas for empirical body surface area (BSA), which is used to estimate body size and standardise physiological parameters, may disagree in children. We compared six commonly used BSA formulas-Du Bois, Boyd, Costeff, Haycock, Meban and Mosteller-in a surgical cohort. This retrospective single-centre cohort study comprised 68 children who had corrective heart surgery at Skåne University Children's Hospital, Lund, Sweden, from February 2010 to March 2017. The children (51% female) underwent surgery at a mean weight of 7.0 kilograms (range 2.7-14.1kg) and a mean age 11months (range 0-43months). All the BSA formulas showed good correlation with mean BSA, but there were considerable variations between them. Mosteller's formula was exactly the same as the mean BSA (bias 0.000). The Du Bois and Boyd formulas had the largest mean BSA deviations (bias -0.012 and 0.015). Costeff's formula showed good agreement with mean BSA, Haycock's formula showed minimal overestimation and Meban's formula demonstrated a systemic error in older children. Commonly used BSA formulas did not agree in young children undergoing heart surgery, but they were all close to the overall mean of the six formulas, with the Mosteller formula producing the same value.

Are neonatal age and small weight predictive of in-hospital death and prolonged hospital stay in children undergoing heart surgery?

BackgroundThe effect of young age and low weight on outcomes of congenital heart disease surgery is controversial. It is still widely believed both by parents and referring cardiologists that they do have a significant deleterious effect and may prohibit surgical care. This study was intended to determine the independent predictors of in-hospital death and prolonged hospital stay in pediatric patients undergoing cardiac surgery. The effects of age and weight were the focus of analysis. To adjust for heterogeneity and complexity, the Risk Adjustment in Congenital Heart Surgery (RACHS-1) system and other factors were used.ResultsAll patients between birth and 18 years of age who underwent cardiac surgery with or without the use of cardiopulmonary bypass from April 1, 2011, to September 30, 2019, were included. Patients undergoing isolated patent ductus ligation were excluded. For the analysis of in-hospital death, a multivariable logistic regression model was used. For the analysis of length of stay, a generalized linear regression model with Poisson distribution and a multivariable logistic regression model were used. The RACHS-1 categories were used to adjust for complexity.The study included 934 index operations. Neonates (age < 28 days) accounted for 11% of the operations. After adjusting for complexity and other operative variables, we found that age and weight were not significant predictors of in-hospital death or prolonged hospital stay. RACHS category and cardio-pulmonary bypass time were, however, significant predictors of in-hospital mortality, p value 0.009, and 0.002, respectively. The complexity of the operation was also predictive of prolonged hospital stay.ConclusionAge and weight are not significant predictors of in-hospital death or prolonged hospital stay. Except for severe prematurity and prohibitive genetic or metabolic disease, patients with CHD should get appropriate and expeditious surgical care regardless of age and weight.

Parents' and healthcare professionals' perceptions of the quality of care: A PITSTOP model of caring.

Quality of care is measured by various indicators. Besides objective quantifications, it is necessary to understand the meaning of quality of care from the perspectives of patients, families, and healthcare professionals. This study aimed to understand parents' and healthcare professionals' perceptions of the quality of care. This was a secondary data analysis of two qualitative studies examining parents' and healthcare professionals' perceptions of caring in 2014 and 2018, respectively. Both studies took place in a children's hospital in the United States. There were 40 participants, 13 parents of children undergoing heart surgery and 27 healthcare professionals. The current study focused on parents' and healthcare professionals' viewpoints about the quality of care. Seven themes emerged: patient-centered care, interprofessional collaboration, team communication, safety and security, trusting relationships, optimal outcomes, and positive patient experiences. The acronym PITSTOP was developed to enable healthcare professionals to recall the elements deemed as important to the quality of care by parents and professionals. This study brought up a novice opinion that healthcare should be like a "pitstop," not just a "repair shop." Healthcare encounters may be brief but invaluable in helping patients and families succeed in their health promotion.

RACHS - ANZ : A Modified Risk Adjustment in Congenital Heart Surgery Model for Outcome Surveillance in Australia and New Zealand.

BackgroundOutcomes for pediatric cardiac surgery are commonly reported from international databases compiled from voluntary data submissions. Surgical outcomes for all children in a country or region are less commonly reported. We aimed to describe the bi‐national population‐based outcome for children undergoing cardiac surgery in Australia and New Zealand and determine whether the Risk Adjustment for Congenital Heart Surgery (RACHS) classification could be used to create a model that accurately predicts in‐hospital mortality in this population.Methods and ResultsThe study was conducted in all children's hospitals performing cardiac surgery in Australia and New Zealand between January 2007 and December 2015. The performance of the original RACHS‐1 model was assessed and compared with an alternative RACHS‐ANZ (Australia and New Zealand) model, developed balancing discrimination with parsimonious variable selection. A total of 14 324 hospital admissions were analyzed. The overall hospital mortality was 2.3%, ranging from 0.5% for RACHS category 1 procedures, to 17.0% for RACHS category 5 or 6 procedures. The original RACHS‐1 model was poorly calibrated with death overpredicted (1161 deaths predicted, 289 deaths observed). The RACHS‐ANZ model had better performance in this population with excellent discrimination (Az‐ROC of 0.830) and acceptable Hosmer and Lemeshow goodness‐of‐fit (P=0.216).ConclusionsThe original RACHS‐1 model overpredicts mortality in children undergoing heart surgery in the current era. The RACHS‐ANZ model requires only 3 risk variables in addition to the RACHS procedure category, can be applied to a wider range of patients than RACHS‐1, and is suitable to use to monitor regional pediatric cardiac surgery outcomes.