Pediatric Cardiac Patients Research Articles

Utilization practices of low molecular weight heparin in pediatric patients with acquired and congenital heart disease

BackgroundEnoxaparin is a commonly used anticoagulant for treatment of thrombosis in pediatric patients. Its use in pediatric cardiac patients has not been well described. We sought to examine the utilization trends, dosing, and safety of enoxaparin in pediatric cardiac patients. MethodsRetrospective study of pediatric cardiac patients treated with enoxaparin from 2011 to 2018. Starting and final doses of enoxaparin, number of dose adjustments, and time to therapeutic anti-factor Xa level were compared between age groups utilizing the Kruskal Wallis test with the Dunn test for pairwise comparisons. ResultsSeventy-one patients were treated with 77 courses of enoxaparin. Most enoxaparin courses were started on patients aged >12 months (40%) and for arterial thrombosis (22 patients, 29%). The most common cardiac diagnosis was hypoplastic left heart syndrome (12 patients, 17%). The mean final dose of enoxaparin was significantly different when comparing patients 0–3-month, 3–12 month, and >12 months (2.1 ± 0.5 mg/kg vs. 1.5 ± 0.4 mg/kg vs. 1.2 ± 1.4 mg/kg, respectively; p < 0.02). Patients 0–3 months and 3–12 months had significantly higher final to initial enoxaparin dose differences than the >12-month age group (0.4 ± 0.4 mg/kg vs. 0.4 ± 0.4 mg/kg vs. 0.1 ± 0.3 mg/kg, respectively; p < 0.01). All age groups needed 2–2.5 days to reach therapeutic anti-Xa levels. Patients aged 0–3 months had significantly more dose changes compared to those >12 months (2.2 ± 1.6 vs. 1.4 ± 1.4, p = 0.02). Antiplatelet therapy was used in 74% of courses. Adverse events were rare and had no relationship to antiplatelet use. ConclusionsEnoxaparin is an effective and safe anticoagulant in pediatric cardiac patients. Initial enoxaparin dosing should be increased from current recommended doses in patients between 3 and 12 months of age to achieve more timely therapeutic anticoagulation.

Rapid Cycle Deliberate Practice to Facilitate "Nano" In Situ Simulation: An Interprofessional Approach to Just-in-Time Training.

Simulation is increasingly used to identify latent threats to patient safety, such as delays in recognition and management of time-sensitive conditions. The Rapid Cycle Deliberate Practice teaching method may facilitate "nano" (brief) in situ simulation training in a critical care setting to improve multidisciplinary team performance of time-sensitive clinical tasks. To determine whether nano-in situ simulation training with Rapid Cycle Deliberate Practice can improve pediatric intensive care unit team proficiency in identifying and managing postoperative shock in a pediatric cardiac patient. A quality improvement educational project was conducted involving nano-in situ simulation sessions in a combined pediatric and pediatric cardiac intensive care unit. The Rapid Cycle Deliberate Practice method was used with an expert-driven checklist for 30-minute simulation scenarios. A total of 23 critical care providers participated. The proportion of time-sensitive tasks completed within 5 minutes increased significantly from before to after training (52% [13 of 25] vs 100% [25 of 25]; P ≤ .001). Using a 5-point Likert scale, with higher scores indicating higher levels, the participants reported high degrees of performance confidence (mean, 4.42; SD, 0.20) and satisfaction with the simulation experience (mean, 4.96; SD, 0.12). The Rapid Cycle Deliberate Practice method was used to facilitate nano-in situ simulation training and identify areas requiring additional education to improve patient safety. In situ simulation can educate providers in a cost-effective and timely manner.

Expanded utilization of rituximab in paediatric cardiac transplant patients.

Epstein-Barr virus (EBV) viraemia and autoimmune cytopenias (AICs) are significant complications that occur following paediatric solid organ transplantation. A variety of treatment methods have been investigated but limited research has focused on the utilization of rituximab in paediatric cardiac transplant recipients for these indications. Rituximab is a monoclonal antibody that binds the CD20 antigen on the surface of B-type lymphocytes resulting in B-cell cytotoxicity. It is considered a second-line therapy for treatment of autoimmune cytopenias and EBV viraemia following adult solid organ transplant (SOT) and haematopoietic stem cell transplant (HSCT). However, data for its use in the paediatric population for treatment of autoimmune cytopenias are lacking. Dosing is based on adult studies, and the frequency and length of therapy associated with resolution of EVB viraemia and AICs in paediatric cardiac transplant recipients is unknown. The objective of this retrospective study was to describe the dosing and length of therapy of expanded off-label use of rituximab for the management of refractory EBV viraemia and AICs, specifically in paediatric cardiac transplant patients. A retrospective chart review was conducted evaluating children <18years of age who underwent cardiac transplantation, were diagnosed with EBV viraemia or autoimmune cytopenia, and subsequently received treatment with rituximab between June 1995 and October 2018. Data were analysed descriptively. Of all (n=188) paediatric cardiac transplant recipients since 1995, 10 patients met the inclusion/exclusion criteria. Primary diagnoses were EBV viraemia (n=6), immune haemolytic anaemia (n=3) and immune thrombocytopenic purpura (n=1). Complete responses were observed in 83.3% and 100% of patients with EVB viraemia and AICs treated with rituximab, respectively. All patients (n=10) received rituximab 325mg/m2 at weekly intervals. The number of total doses associated with complete resolution was 4-6 doses for EBV viraemia and 2-4 doses for AICs. The most common adverse events reported were neutropenia (n=3), thrombocytopenia (n=4), infusion reactions (n=1) and significant anaemia (n=2). Although the efficacy of rituximab for treatment of EBV viraemia and autoimmune cytopenia in the paediatric cardiac transplant population remains unclear, our study supported the benefit of rituximab when added to therapy for treatment of EBV viraemia and ACIs.

Mitochondrial Transplantation for Ischemia Reperfusion Injury.

Mitochondrial transplantation is a novel therapeutic intervention to treat ischemia-reperfusion-related disorders. This approach uses replacement of native mitochondria with viable, respiration-competent mitochondria isolated from non-ischemic tissue obtained from the patient's own body, to overcome the many deleterious effects of ischemia-reperfusion injury on native mitochondria. The safety and efficacy of this methodology has been demonstrated in cell culture, animal models and has been shown to be safe and efficacious in a phase I clinical trial in pediatric cardiac patients with ischemia-reperfusion injury. These studies have demonstrated that mitochondrial transplantation rescues myocardial cellular viability and significantly enhances postischemic myocardial function following ischemia-reperfusion injury. Herein, we describe methodologies for the delivery of isolated mitochondria.

Effects of regional differences on the outcome of cardiopulmonary resuscitation in children: How much different is Gaziantep from Izmir?

OBJECTIVES:We aimed to compare the demographic and clinical characteristics between pediatric cardiac arrest patients treated in Gaziantep at South-eastern Anatolian region and Izmir at Aegean Shore.MATERIALS And METHODS:We retrospectively reviewed sociodemographic characteristics, laboratory parameters, and clinical outcomes of pediatric patients that underwent cardiopulmonary resuscitation due to prehospital cardiac arrest at two pediatric emergency departments in Izmir Hospital of Health Sciences University and Gaziantep Cengiz Gökçek Kadın Doğum ve Çocuk Hospital of Health Ministry between August 2017 and August 2018.RESULTS:The present study included 188 patients (112 patients from Gaziantep and 76 patients from Izmir). All patients arrived at the hospital through emergency medical services. The median age was lower (14 days vs. 15 months; P < 0.001), and the proportion of Syrian refugees was higher in patients from Gaziantep (78.6% vs. 7.9%; P < 0,001). In both centers, respiratory failure was the most common etiology. In patients from Gaziantep, pH levels were lower (median: 7.10 vs. 7.24), and lactate levels were higher (median: 6 mmol/L vs. 3.6 mmol/L; P < 0.001). The mortality rate was higher among patients from Gaziantep (27.7% vs. 7.9%; P = 0.001).CONCLUSIONS:The rate of Syrian refugees among children who were brought to emergency department due to pre-hospital cardiac arrest was much higher in Gaziantep compared to Izmir. Syrian children were significantly younger and had more severe tissue hypoxia, resulting in a higher mortality rate.

Complex congenital heart diseases among children presenting for cardiac surgery in a tertiary health facility in Enugu; South-East Nigeria. A rising trend.

Complex cardiac anomalies are a set of associated heart structural anomalies requiring some adaptive mechanism to maintain life. This is to determine pattern and prevalence of common complex cardiac anomalies among children presenting for cardiac surgery in Enugu. The children that present for cardiac surgery in our center over a six-month period were admitted and rescreened using a standardized echocardiographic method, information on biodata, oxygen saturation and 2D echo diagnosis were recorded in a proforma. A hundred and one (101) children with different structural heart diseases presented for cardiac surgery, 53 females and 48 males, 99 (98%) had congenital heart defects (49 cyanotic and 50 acyanotic). Complex cardiac anomalies were noted among 49 and 50 were non-complex, 6 (12.2%) acyanotic, and 43 (87.8%) cyanotic complex P < 0.01. This was noted among 21 females and 28 males. Children less than 3 years had 31 cases (63.3%) of the complex heart diseases while children between 5 years to 18 years had 14 (28.6%). The top three complex congenital heart disease were complex Tetralogy of Fallot which was found among 26 (53%) subjects. Tricuspid atresia and Truncus arteriosus were found in 3 children with congenial heart disease each, Shone complex was found in a child, Hypoplastic left heart syndrome was also noted in a child. The incidence of complex congenital heart diseases among prospective Paediatric cardiac surgery patients is high. Efforts should be made to improve access to preventive cardiology in order to curb these diseases.

Efficacy of paravertebral block in “Fast-tracking” pediatric cardiac surgery - Experiences from a tertiary care center

Introduction:Fast tracking plays a crucial role in reducing perioperative morbidity and financial burden by facilitating early extubation and discharge from hospital. Paravertebral block (PVB) is becoming more popular in paediatric surgeries as an alternative to epidural and caudal analgesia. There is scarcity of data regarding the efficacy and safety of PVB in paediatric cardiac surgery.Methods:We performed a review of records of paediatric cardiac patients who underwent cardiac surgery under general anaesthesia with single shot PVB and compared the analgesia and postoperative outcomes with matched historical controls who underwent cardiac surgery with same anaesthesia protocol without PVB.Results:The data from 200 children were analysed. 100 children who received paravertebral block were compared with a matched historical controls. The median time to extubation was shorter in the PVB group (0 hr, IQR 0-3 hrs) compared to the control group (16 hrs, IQR 4-20 hrs) (P value 0.017*). Intraoperative and postoperative fentanyl requirement was much lower in the PVB group (3.49 (0.91)) compared to the control group (9.86 (1.37)) P value <0.01*. Time to first rescue dose of analgesic was longer (7 hrs vs 5 hrs, P 0.01*), while time to extubation and duration of ICU stay were significantly less in PVB group . Mean postoperative pain scores were significantly lower in the PVB group at the time of ICU admission (0.85 vs 3.12, P 0.001*) till 4 hours (2.11 vs 3.32, P 0.001*).Conclusion:PVB provides an effective and safe anaesthetic approach which can form an important component of “fast-track” care in paediatric cardiac surgery.

Higher Child-Reported Internalizing and Parent-Reported Externalizing Behaviors were Associated with Decreased Quality of Life among Pediatric Cardiac Patients Independent of Diagnosis: A Cross-Sectional Mixed-Methods Assessment

Background: Pediatric cardiology patients often experience decreased quality of life (QoL) and higher rates of mental illness, particularly with severe disease, but the relationship between them and comparisons across diagnostic groups are limited. This mixed-methods cross-sectional study assessed the association between QoL anxiety and behavior problems among children with structural heart disease, arrhythmia, or other cardiac diagnoses. Methods: Children (6–14 years, n = 76, 50% female) and their parents completed measures of QoL (PedsQL), behavior (BASC-2, subset of 19 children) and anxiety (MASC-2, children 8+ years). Pearson correlations/regression models examined associations between QoL, behavior and anxiety, controlling for age, sex, diagnosis and condition severity. Student t-tests compared results to published normative values. Semi-structured interviews (15 children, 13 parents) examined self- and parent-reported perceptions of the patient’s emotional health. Results: Child reported social QoL (95% CI difference: −11.0, −2.1), emotional well-being (95% CI difference: −12.5, −3.8) and adjustment skills (95% CI difference: −13.9, −3.0) were significantly below published norms (p < 0.05). Neither age, sex, nor diagnosis were significantly related to questionnaire responses. Compared to children with mild conditions, child and parent-reported QoL was significantly lower in children with complex conditions (np2 ≥ 0.14, p < 0.05). Lower QoL was strongly associated with more internalizing problems based on both child (r = −0.78, p < 0.001) and parent (r = −0.67, p < 0.001) reports. Interview responses suggested emotional distress was attributed to “normal” child problems rather than the child’s cardiac problem. Conclusion: Children with complex cardiac conditions, regardless of diagnosis, had diminished QoL. Using the PedsQL in clinical settings may help identify pediatric cardiology patients experiencing emotional distress (i.e., anxiety and depression).

Measures of anticoagulation and coagulopathy in pediatric cardiac extracorporeal membrane oxygenation patients.

Pediatric cardiac Extracorporeal Membrane Oxygenation (ECMO) is effective, however, bleeding and clotting issues continue to cause significant morbidity and mortality. The objective of this study was to assess the correlation between measures of anticoagulation, the heparin dose in pediatric cardiac ECMO patients as well as to assess covert coagulopathy as measured by thromboelastography (TEG). Retrospective study of cardiac ECMO patients in a large, academic referral center using anticoagulation data during the ECMO support. Five hundred and eighty-four sets of anticoagulation tests and 343 TEG from 100 patients with median age of 26 days were reviewed. ECMO was post-surgical for congenital heart disease in 94% with resuscitation (ECPR) in 38% of the cases. Mean duration of support was 6.3 days. Overall survival to discharge was 35%. There was low but statistically significant correlation between individual anticoagulation measures and low correlation between Anti-Xa levels and heparin dose. There was no correlation between PTT and heparin dose. 343 TEG with Heparinase were reviewed to assess covert coagulopathy which was present in 25% of these. The coagulopathy noted was pro-hemorrhagic in almost all of the cases with high values of reaction time and kinetics and low values for angle and maximum amplitude. Coagulation monitoring on ECMO may benefit from addition of Heparinase TEG to diagnose covert coagulopathy which can contribute to significant hemorrhagic complications. There is a need for a prospective, thromboelastography guided intervention trial to reduce coagulopathy related morbidity and mortality in ECMO.

Transthoracic intracardiac catheters in perioperative management of pediatric cardiac surgery patients: a single-center experience.

Transthoracic intracardiac catheters inserted under direct vision in the pulmonary artery and left atrium during cardiac surgery play major roles in the management of patients with complex congenital heart disease. We aimed to analyze the utility of transthoracic intracardiac catheters in the perioperative management of pediatric cardiac surgery patients and review catheter-related morbidity. The computerized register of all pediatric cardiac surgery patients in whom transthoracic intracardiac catheters were inserted from 2012 to 2019 in a tertiary referral center were reviewed. Transthoracic pulmonary artery and left atrial catheters were inserted in 89 and 71 patients, respectively. The most common indications for pulmonary artery and left atrial catheters were total anomalous pulmonary venous connection (52%) and total cavopulmonary connection (58%) respectively. The most common reason for elevated pulmonary artery and left atrial pressure after cardiopulmonary bypass was left ventricular dysfunction. Transthoracic pulmonary artery catheters helped in diagnosing pulmonary hypertensive crisis (29%), surgical decision-making (14%), and ventilator therapy (16%). Left atrial catheters helped in the diagnosis of left ventricular dysfunction (54%). The incidence of morbidity was 8.9% for transthoracic pulmonary artery catheters and 9.8% for left atrial catheters. Transthoracic pulmonary artery catheters help in the diagnosis and management of pulmonary hypertensive crisis, for making perioperative surgical decisions, and during ventilator therapy. Transthoracic left atrial catheters help in the diagnosis of left ventricular dysfunction in the perioperative period. The diagnostic and treatment benefits provided by transthoracic intracardiac catheters outweigh the minor adverse events, supporting their continued use in the perioperative period.

Risk Recognition and Multidisciplinary Approach for Non-Cardiac Surgeries in Paediatric Cardiac Patients: A Retrospective Observational Study

BackgroundCongenital heart disease (CHD), a structural and functional heart disease, is the commonest birth defect with an incidence of one in 125 live births worldwide with ventricular septal defect (VSD), atrial septal defect (ASD) and tetralogy of Fallot (TOF) constituting the majority. Surgery for associated extra-cardiac anomalies (airway, skeletal, genitourinary, and gastrointestinal) may be required in 30% of these patients. Delivery of uneventful anaesthesia in these children requires an understanding of not only paediatric anaesthesia but also of the pathophysiology of the cardiac lesion and its associated risks.AimsThe purpose of this retrospective review was to highlight the approach to the anaesthetic management and outcomes of patients with significant cardiac lesions presenting for non-cardiac surgeries.Material and methodsA retrospective chart review of all children with congenital heart disease (CHD) (repaired or unrepaired) who were posted for a non-cardiac surgery in this tertiary care Paediatric super-specialty hospital from January 1, 2018 to December 31, 2019 was carried out. Data on demographics, peri-operative management, and clinical course was retrieved.Inclusion criteria were paediatric patients (0-18 years) of either gender with a diagnosis of a CHD (repaired or unrepaired) undergoing any non-cardiac surgeries (NCS) under anaesthesia/Monitored Anaesthesia Care (MAC).Exclusion criteria were procedures only under local anaesthesia (LA) or a minor procedure done solely under sedation not involving an anaesthesiologist.ResultsDuring the study period, we found five eligible cases who underwent a total of six procedures. Five procedures were elective and one was an emergency. Preoperative optimization was conducted by a multidisciplinary team including paediatric surgeons, anaesthesiologists, physicians, and cardio-thoracic surgeons. Anaesthesia was conducted by at least a consultant paediatric anaesthesiologist. Overall all patients tolerated anaesthesia well without any adverse events or complications. All six anaesthetic encounters were safe and uneventful.

Outcomes of Delayed Sternal Closure in Paediatric Cardiac Surgical Patients–A Prospective Single Centre Study

Abstract Background Delayed sternal closure (DSC) is being increasingly used as an interim support to help the dysfunctional heart in the road to recovery after complex pediatric cardiac surgeries. The purpose of this study was to assess the conduct of DSC at a tertiary care center. Methods Between 2018 and 2019, 185 consecutive pediatric patients (below 12 years of age) underwent cardiac surgery at a tertiary care center. The incidence and causes of DSC were noted. The various pre, intra and postoperative factors till discharge or demise were noted and analyzed. Results In this study, DSC was done in 63 patients (34.05%) with a median age and weight of 29 days (18–100 days) and 4 kg (2–12.3 kg), respectively. Transposition of great arteries (TGA) (41.27%) constituted the majority, followed by total anomalous pulmonary venous connection (TAPVC) (26.98%). Myocardial edema (49.21%) was the most common indication for DSC. Mean duration of open chest was 40.75 ± 18.58 hours. All-cause mortality was 19.05% (12/63). On multivariate analysis by logistic regression, the independent predictors of mortality were needed for preoperative mechanical ventilation (OR 42.82, 95% CI = 4.52–406.03, p &lt; 0.001) and development of postoperative sepsis (OR 20.07, 95% CI = 2.12–189.80, p = 0.002). Conclusions DSC is a safe and effective technique in the management of complex pediatric cardiac surgeries. It provides assistance to the severely dysfunctional myocardium soon after the surgery and helps in stabilization of hemodynamics with avoidance of postoperative mediastinal compression. Early sternal closure should be considered on the basis of cardiovascular function and/or resolution of primary indication for DSC.

Total Lymphoid Irradiation in The Treatment and Prevention of Pediatric Cardiac Allograft Rejection — A 23-Year Experience

Despite the development of increasingly efficacious immunosuppressive agents, allograft rejection is still a leading cause of morbidity and mortality in pediatric heart transplant patients. Total lymphoid irradiation (TLI) has emerged as a secondary treatment for recurrent cardiac allograft rejection refractory to medication in adults. However, there is limited evidence for long-term TLI efficacy and safety in the pediatric cohort. Our objectives were to evaluate 1) the long-term effects of TLI in treating recurrent pediatric cardiac allograft rejections at a single institution, and 2) the outcome of a unique prophylactic TLI protocol for re-transplant cardiac allograft in pediatric patients. This study included pediatric cardiac transplant patients who received TLI between 1996 and 2014, and who underwent regular right ventricular endomyocardial biopsies. TLI of 800 cGy in 10 fractions was delivered twice a week to the mantle and periaortic/splenic fields. Indication of TLI for treatment of allograft rejection included recurrent episodes (≥ 3) of rejection (defined as ISHLT Grade ≥ 1B/1R) or rejection episodes that failed to respond to medical therapy. Prophylactic TLI was indicated for patients who received a re-transplant cardiac allograft. Follow-up on these patients ended on January 23, 2020, comprising of 23 years of single institutional data. Comparisons in endpoints were performed using paired-sample, non-parametric tests. Eighteen patients underwent TLI for treatment of recurrent cardiac allograft rejection (n = 11, treatment cohort) and/or for rejection prevention in a re-transplant graft (n = 10, prophylactic cohort). Three patients completed 2 courses of TLI for both treatment and prevention of graft rejection. Median follow up was 10.1 years (range 0.5-23 years). In the treatment cohort, TLI demonstrated a trend to prolong the time to graft rejection, from a median of 62 days before TLI to 320 days after TLI (p = 0.054). In the prophylactic cohort, TLI increased ten-year graft survival from 11.1% to 44.4% (n = 9 due to a patient lost to follow-up; p = 0.38). Nine out of 10 patients underwent re-transplant due to graft coronary artery disease in the initial allograft – 1 patient developed coronary vessel narrowing in the re-transplant graft requiring a drug-eluting stent 17.1 years after prophylactic TLI, while the other 8 patients had no evidence of any narrowing, stenosis, or coronary allograft vasculopathy (CAV) in the re-transplant graft (mean CAV-free graft survival 9.4 years). During long-term follow-up, there was no incidence of hematological malignancies or blood dyscrasias. Our study showed that TLI was well tolerated and safe in long-term follow-up. It not only demonstrated a trend to prolong the time to graft rejection, but also showed promising results in preventing CAV and lengthening graft survival if given prophylactically. Further investigation into the role of treatment and prophylactic TLI is warranted.

Clinical descriptors of pneumothorax following chest tube removal in paediatric cardiac surgery.

There is limited data describing the characteristics of paediatric post-operative cardiac surgery patients who develop pneumothoraces after chest tube removal. Patient management after chest tube removal is not standardised across paediatric cardiac surgery programmes. The purposes of this study were to describe the frequency of pneumothorax after chest tube removal in paediatric post-operative cardiac surgical patients and to describe the patient and clinical characteristics of those patients who developed a clinically significant pneumothorax requiring intervention. A single-institution retrospective descriptive study (1 January, 2010-31 December, 2018) was utilised to review 11,651 paediatric post-operative cardiac surgical patients from newborn to 18 years old. Twenty-five patients were diagnosed with a pneumothorax by chest radiograph following chest tube removal (0.2%). Of these 25 patients, 15 (1.6%) had a clinically significant pneumothorax and 8 (53%) did not demonstrate a change in baseline clinical status or require an increase in supplemental oxygen, 14 (93%) required an intervention, 9 (60%) were <1 year of age, 4 (27%) had single-ventricle physiology, and 5 (33%) had other non-cardiac anomalies/genetic syndromes. In our cohort of patients, we confirmed the incidence of pneumothorax after chest tube removal is low in paediatric post-operative cardiac surgery patients. This population does not always exhibit changes in clinical status despite having clinically significant pneumothoraces. We suggest the development of criteria, based on clinical characteristics, for patients who are at increased risk of developing a pneumothorax and would require a routine chest radiograph following chest tube removal.

Prevalence of ICU Delirium in Postoperative Pediatric Cardiac Surgery Patients.

The objective of this study was to determine the prevalence of ICU delirium in children less than 18 years old that underwent cardiac surgery within the last 30 days. The secondary aim of the study was to identify risk factors associated with ICU delirium in postoperative pediatric cardiac surgical patients. A 1-day, multicenter point-prevalence study of delirium in pediatric postoperative cardiac surgery patients. Twenty-seven pediatric cardiac and general critical care units caring for postoperative pediatric cardiac surgery patients in North America. All children less than 18 years old hospitalized in the cardiac critical care units at 06:00 on a randomly selected, study day. Eligible children were screened for delirium using the Cornell Assessment of Pediatric Delirium by the study team in collaboration with the bedside nurse. Overall, 181 patients were enrolled and 40% (n = 73) screened positive for delirium. There were no statistically significant differences in patient demographic information, severity of defect or surgical procedure, past medical history, or postoperative day between patients screening positive or negative for delirium. Our bivariate analysis found those patients screening positive had a longer duration of mechanical ventilation (12.8 vs 5.1 d; p = 0.02); required more vasoactive support (55% vs 26%; p = 0.0009); and had a higher number of invasive catheters (4 vs 3 catheters; p = 0.001). Delirium-positive patients received more total opioid exposure (1.80 vs 0.36 mg/kg/d of morphine equivalents; p < 0.001), did not have an ambulation or physical therapy schedule (p = 0.02), had not been out of bed in the previous 24 hours (p < 0.0002), and parents were not at the bedside at time of data collection (p = 0.008). In the mixed-effects logistic regression analysis of modifiable risk factors, the following variables were associated with a positive delirium screen: 1) pain score, per point increase (odds ratio, 1.3; 1.06-1.60); 2) total opioid exposure, per mg/kg/d increase (odds ratio, 1.35; 1.06-1.73); 3) SBS less than 0 (odds ratio, 4.01; 1.21-13.27); 4) pain medication or sedative administered in the previous 4 hours (odds ratio, 3.49; 1.32-9.28); 5) no progressive physical therapy or ambulation schedule in their medical record (odds ratio, 4.40; 1.41-13.68); and 6) parents not at bedside at time of data collection (odds ratio, 2.31; 1.01-5.31). We found delirium to be a common problem after cardiac surgery with several important modifiable risk factors.

Bivalirudin May Reduce the Need for Red Blood Cell Transfusion in Pediatric Cardiac Patients on Extracorporeal Membrane Oxygenation.

We retrospectively compared anticoagulation with heparin and bivalirudin for 32 consecutive children under 18 years old during extracorporeal membrane oxygenation (ECMO) in our pediatric cardiac intensive care unit (PCICU). Between September 2015 and January 2018, 14 patients received heparin, 13 venoarterial (VA), and 1 venovenous (VV). From February 2018 to September 2019, 18 received bivalirudin (all VA). The mean (standard deviation [SD]) percentage of time with therapeutic activated partial thromboplastin time and activated clotting time was bivalirudin 54 (14%) and heparin 57 (11%), p = 0.4647, and percentage of time supratherapeutic was bivalirudin 18 (10%) and heparin 27 (12%), p = 0.0238. Phlebotomy-associated blood loss per hour of ECMO was double in the heparin compared with bivalirudin group 1.08 ml/h (0.20 ml/h), compared with 0.51 ml/h (0.07 ml/h), p = 0.0003, as well as interventions to control bleeding. Packed red blood cell (PRBC) transfusions significantly correlated with higher blood loss in the heparin group (Pearson correlation coefficient = 0.49, p = 0.0047). Overall amount of blood product utilization was not different between the groups. Survival to ECMO decannulation was 89% for bivalirudin and 57% for heparin, p = 0.0396, although 6 month survival was not significantly different (67% versus 57%, p = 0.5809). Heparin may increase the need for PRBC transfusions and strategies to attenuate bleeding when compared with bivalirudin for children receiving ECMO in PCICU.

The feasibility of measurement of different right ventricular systolic function parameters by intraoperative trans-esophageal echocardiography and their interchangeability with transthoracic echocardiography in pediatric patients undergoing cardiac surgery- interim results from an ongoing study

Introduction All the parameters recommended for functional assessment of right ventricle (RV) in children are based on transthoracic echocardiographic (TTE) measurements¹. Intraoperative echocardiography during pediatric cardiac surgery is, however, mainly dependent on trans-esophageal echocardiography (TEE). We planned to determine the feasibility of measurement of different RV systolic function parameters by intraoperative TEE and their interchangeability with TTE in pediatric patients undergoing cardiac surgery. Methods This ongoing single-centre, observational study has been registered (CTRI/2019/06/019743) after Institutional Ethics Committee clearance. After written, informed, parental consent, pediatric patients (1-18 years) undergoing corrective surgery for congenital heart diseases- are included. TEE transducer is inserted after induction of general anaesthesia. TTE examination is performed using Apical four-chamber (A4C) view. TEE examination is performed within 10 minutes of performing TTE, while keeping heart rate, mean arterial pressure and central venous pressure within 10% of that during performing TTE. Mid-esophageal four-chamber RV-focused (ME4C) view, Mid-esophageal modified bicaval view (MBC), Transgastric RV inflow view (TGRVI), Deep transgastric RV view (DTG-RV)- are used. All the recorded images/clips are analysed offline later, using Echopac-113 (GE) software. Fractional Area Change (FAC), Tricuspid annular plane systolic excursion (TAPSE), Tricuspid annular systolic velocity by pulsed-wave tissue Doppler (RV S’), Right ventricular index of myocardial performance (RIMP) (by tissue Doppler), Right ventricular free wall strain (RVFWS)- are measured. Feasibility is assessed as ability to acquire an image/loop deemed readable during the examination. Readable image/loop is defined as ability to completely delineate the endocardial border of the RV and tricuspid annulus in 2D-mode, to obtain completely traceable lines in M-mode (MM) and Angled M- mode (AMM), to obtain optimally aligned and completely traceable envelopes of pulsed wave Tissue-Doppler velocities. Agreement between TTE and TEE measured parameters are assessed by Bland-and-Altmann analysis. Results 42 patients has been recruited and analysed so far. The Mean±SD age of the patients was 6.5±4.6 years. Feasibility of measuring all the studied parameters was > 85% in all the TEE views (Table 1). There was good Intra- and Inter-observer reliability (Intra-class Correlation Coefficient > 0.8) of measurements of all the parameters in all the views (Both TTE and TEE) utilised. In comparison to TTE measurements, there were low bias in TEE measured parameters in: AMM measured TAPSE in ME4C and MBC views, FAC in ME4C view, RIMP in DTG-RV and TGRVI views, RVFWS in all the utilised views (Table 1). The limits of agreements, however, were wide (Table 1). Discussion Despite high feasibility, wide limits of agreement prevents intraoperative TEE measured RV function parameters to be used interchangeably with those measured by TTE for individual pediatric cardiac surgical patients.

Performance of an analysis-through-cpr shock advisory algorithm on pediatric cardiac arrest patients

Introduction: We previously reported an algorithm that can identify shockable rhythms through chest compressions (CCs) and its performance on adult patients. In the present study, the algorithm's performance on pediatric patients was evaluated.

Effects of intraoperative dexmedetomidine on the incidence of acute kidney injury in pediatric cardiac surgery patients: A randomized controlled trial.

Perioperative dexmedetomidine use has been reported to reduce the incidence of postoperative acute kidney injury after adult cardiac surgery. However, large-scale randomized controlled trials evaluating the effect of dexmedetomidine use on acute kidney injury in pediatric patients are lacking. We investigated whether intraoperative dexmedetomidine could reduce the incidence of acute kidney injury in pediatric cardiac surgery patients. In total, 141 pediatric patients were randomly assigned to dexmedetomidine or control groups. After anesthetic induction, patients in the dexmedetomidine group were administered 1µg/kg of dexmedetomidine over 10minutes and an additional 0.5µg/kg/h of dexmedetomidine during surgery. Additionally, 1µg/kg of dexmedetomidine was infused immediately after cardiopulmonary bypass was initiated. The incidence of acute kidney injury was defined following Kidney Disease Improving Global Outcomes guidelines. The final analysis included 139 patients. The incidence of acute kidney injury did not differ between dexmedetomidine and control groups (16.9% vs 23.5%; odds ratio 0.661; 95% CI 0.285 to 1.525; P=.33). Similarly, neither the incidence of abnormal postoperative estimated glomerular filtration rate values (P=.96) nor the incidence of arrhythmia, mechanical ventilation duration, length of stay in the intensive care unit, and hospitalization differed between the two groups. Intraoperative dexmedetomidine did not reduce acute kidney injury incidence in pediatric cardiac surgery patients.

Scavenging right atrial Bretschneider histidine-tryptophan-ketoglutarate cardioplegia: Impact on hyponatremia and seizures in pediatric cardiac surgery patients

ObjectiveCustodiol-HTK cardioplegia (Custodiol-HTK Koheler Chemie, GmbH, Bensheim, Germany) causes fluctuations in serum sodium levels, hyponatremia, and is associated with postoperative seizures. We investigated the influence of scavenging right atrial effluent during delivery on intraoperative serum sodium levels and postoperative seizure incidence in pediatric cardiac surgery patients. MethodsA total of 204 patients younger than age 18 years undergoing congenital heart surgery between January 2016 and March 2018 were analyzed retrospectively. Serum sodium levels after administration of Custodiol-HTK cardioplegia were compared between the scavenge and nonscavenge groups and then in the propensity score-matched cohort (n = 96). Postoperative seizures were documented clinically and with electroencephalogram findings. Logistic regression models were used to identify the independent predictors of serum sodium level after aortic crossclamp. ResultsOf 204 patients, 156 (76.5%) were in the nonscavenge, and 48 (23.5%) in the scavenge groups. A serum sodium level <130 mEq/L after crossclamp and administration of Custodiol-HTK cardioplegia in the nonscavenge group were 70% versus 21% in the scavenge group (odds ratio, 8.8; 95% confidence interval, 4.1-18.3; P < .0001) in the entire cohort, and 77% versus 21% (odds ratio, 12.8; 95% confidence interval, 4.8-33.1; P < .0001) in the propensity score-matched cohort. Of 16 patients experiencing a postoperative seizure, 14 (87.5%) had a sodium level <130 mEq/L and 2 (12.5%) had a sodium level ≥130 mEq/L (odds ratio, 5.1; 95% confidence interval, 1.3-22.8; P = .021) after crossclamp. Postoperative seizures occurred in the nonscavenge group but not the scavenge group in the entire cohort (P = .02) and in the propensity score-matched patients (P = .041). Multivariable analysis of the entire cohort showed that scavenge intervention was an independent factor associated with significantly decreased risk of sodium level <130 mEq/L (odds ratio, 0.17; 95% confidence interval, 0.08-0.36; P = .000). ConclusionsRight atrial effluent scavenging was protective against fluctuations in serum sodium levels after crossclamp and Custodiol-HTK cardioplegia administration independently in both entire and matched cohort, and was also associated with decreased incidence of postoperative seizures.