Pediatric Cardiac Patients Research Articles

Direct postoperative protein S100B and NIRS monitoring in infants after pediatric cardiac surgery enrich early mortality assessment at the PICU

BackgroundNeuromonitoring using plasmatic biomarkers such as S100B and near-infrared spectroscopy (NIRS) represents a standard procedure for detecting cerebral damage after cardiac surgery. Their use in pediatric clinical assessment, however, is negligible. ObjectivesThe goal of this study was to evaluate the predictive role of S100B levels and cerebral oxygenation in postoperative pediatric cardiac patients for survival and potential cerebral injuries. MethodsA retrospective cohort study of infants after cardiac surgery. Primary outcome was survival until discharge. Intra/postoperative vital signs and laboratory data were measured and statistically analyzed. ResultsSeven out of 226 infants were non-survivors. Non-survivors had significantly lower cerebral saturation than survivors, as well as elevated S100B values at admission, associated with lower arterial pressure and higher serum lactate levels. ConclusionAlthough significant differences of S100B and crO2 values between survivors and non-survivors were found, no critical thresholds could be established from the data. Nevertheless, changes from the norm in these parameters should raise awareness for critical clinical development.

Noninvasive monitoring of central venous oxygen saturation by jugular transcutaneous near-infrared spectroscopy in pediatric patients undergoing congenital cardiac surgery

Background and aimIn patients undergoing congenital cardiac surgery, it is crucial to maintain oxygen demand-consumption balance. Central venous oxygen saturation (ScvO2) is a useful indicator of oxygen demand and consumption balance which is an invasive method. Near-infrared spectroscopy (NIRS) is a noninvasive, continuous monitoring technique that measures regional tissue oxygenation. NIRS that is placed over the internal jugular vein cutaneous area (NIRSijv) has the potential to show ScvO2 indirectly. In this study, we aimed to determine the correlation between ScvO2 with NIRSijv in pediatric patients undergoing congenital cardiac surgery.Materials and methodsFifty children participated in the study. Four patients were excluded for the inability of internal jugular vein (IJV) catheterization due to technical difficulties. After anesthesia induction, NIRS probes were placed on the IJV site with ultrasound guidance for the measurement of continuous transcutaneous oxygen saturation. The catheter insertion was also done through the IJV from the other side using ultrasound guidance. Cerebral oxygenation monitoring was done using NIRS with a single pediatric probe placed on the right forehead. Values of NIRSijv, cerebral NIRS (NIRSc) and ScvO2, were recorded at certain times until postoperative 24th hour.ResultsData were collected at 8 different time points. There was a significant correlation between ScvO2 and NIRSijv in all measurement time points (r = 0.91), (P = 0.001). The mean bias between ScvO2 and NIRSijv was 2.92% and the limits of agreement were from 11% to –5.2%. There was a moderate correlation between ScvO2 and NIRSc (r = 0.45), (P = 0.001). The mean bias between ScvO2 and NIRSc was 2.7% and the limits of agreement were from +26% to –20%.ConclusionIn this study, we found a strong correlation between ScvO2 and NIRS measurements taken from the internal jugular vein site. Accordingly, continuous noninvasive monitoring with transcutaneous NIRSijv can be an alternative method as a trend monitor for the central venous oxygen saturation in pediatric cardiac patients undergoing congenital cardiac surgery.

P55 Immunosuppression in the first six weeks following paediatric cardiac transplant

AimThe aim of this audit was to establish whether immunosuppression was being prescribed correctly and whether target levels were being reached during the first six weeks post-transplant.1 2MethodThe standards were discussed and agreed, due to an absence of standardised local or national written protocols, with the lead paediatric cardiothoracic transplant consultant and a specialist transplant liaison nurse. The paediatric transplant database provided a list of patients between October 2016 and July 2018, from which paediatric cardiac transplant patients were included in this audit. All data were collected retrospectively, for the first six weeks post-transplant, from patient’s electronic records.ResultsTwenty-three patients were included in the audit; fifteen males and eight females and the mean age was 6 years old. The standards for the timing and dosing of the first ciclosporin dose were met for 87% and 78% of patients respectively. Six patients (26%) had a ciclosporin level within the target range by day 4 post-transplant, for the remaining seventeen patients the average was day 9 post-transplant. The mean levels remained within this range or slightly above after day 9. Azathioprine or mycophenolate was started within 7 days of transplant in 6 patients (23%). Four patients (17%) had documented episodes of rejection; in one patient all other standards were met and in the other three only one additional standard was not met. Nineteen patients (83%) did not have a documented episode of rejection.ConclusionsPost-transplant management is individualised based on multiple factors such as clinical conditions e.g. renal/liver impairment and whether other agents such as ATG or steroids are being used.1 The lack of documentation around the treatment decisions made it difficult to explain deviations from standards in this audit. Ciclosporin standards were not met completely but were most likely unfeasible due to a narrow target range and the time between first dose and level monitoring. There did not appear to be a clear association between standards not being met and episodes of rejection. It would be beneficial to repeat this as a larger, prospective audit using revised standards.ReferencesCostanzo MR, Costanzo MR, Dipchand A, et al. The international society of heart and lung transplantation guidelines for the care of heart transplant recipients. J Heart Lung Transplant 2010;29:914–56.Sandimmun Concentrate for Solution for Infusion 50 mg/ml - Summary of Product Characteristics (SmPC) - (eMC) [Internet]. [cited 2018 Sep 2]. Available from: https://www.medicines.org.uk/emc/product/1036

The landscape of paediatric in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit

AimTo report the patient characteristics and clinical outcome of paediatric in-hospital cardiac arrest in the United Kingdom (UK) National Cardiac Arrest Audit (NCAA) database. MethodsAnalysis of all recorded paediatric cardiac arrests in the NCAA dataset over a seven-year period ending on 31 December 2018, within acute children’s hospitals (including standalone paediatric hospitals and hospitals with tertiary paediatric services) and acute general hospitals participating in NCAA. In this period 1456 patients (with 1580 events), 1 month to 16 years of age, received chest compressions and/or defibrillation and were attended by a hospital-based resuscitation team in response to an emergency call. The main outcome measure was survival to discharge. ResultsFor this cohort of paediatric in-hospital cardiac arrest patients the overall rates of sustained return of spontaneous circulation (ROSC) were 69.1% with unadjusted survival to hospital discharge of 54.2%. The presenting rhythm was shockable in 4.3% of events and non-shockable in 82.1% (remainder undetermined); rates of survival to hospital discharge associated with these rhythms were 63.9% and 51.7%. A difference in outcomes was observed between Children’s hospitals and acute general hospitals with ROSC rates of 79.1% and 55.5% respectively and survival to hospital discharge rates of 57.7% and 49.3% respectively. ConclusionsThese first results from the NCAA database describing the outcome of paediatric in-hospital cardiac arrest in UK hospitals will serve as a benchmark from which to assess the future impact of changes in service delivery, organisation and treatment for in-hospital cardiac arrest in young people. Outcomes for specialist paediatric centres should be studied further as higher rates of ROSC and survival to hospital discharge were observed.

Use of Factor VIIa and Anti-inhibitor Coagulant Complex in Pediatric Cardiac Surgery Patients

Postoperative bleeding is a common cause of morbidity and mortality in cardiac patients who undergo cardiopulmonary bypass (CPB). Pediatric patients are especially at risk for adverse effects of surgery and CPB on the coagulation system. This can result in bleeding, transfusions, and poor outcomes. Excessive bleeding unresponsive to blood products can warrant the off-label use of recombinant activated clotting factor VIIa (rFVIIa) and/or anti-inhibitor coagulant complex (FEIBA). Several studies have shown the utility in these agents off-label in patients who have undergone cardiac bypass surgery with acute bleeding episodes that are refractory to blood products. However, data regarding use of these agents in pediatrics are sparse. The purpose of this study is to report the use of rFVIIa and FEIBA in pediatric cardiac surgery patients in our institution. This was a retrospective chart review of pediatric cardiothoracic surgery patients who received rFVIIa or FEIBA at Children's Healthcare of Atlanta during the study period. Thirty-three patients received rFVIIa and 9 patients received FEIBA either intraoperatively or postoperatively for bleeding related to the cardiac procedure. Approximately 13% of rFVIIa patients and 55% of FEIBA patients required repeat doses. There were decreases for all blood products administered after rFVIIa and FEIBA were given. However, the doses used did not correlate with either positive or negative outcomes. Seventeen percent (n = 7) of rFVIIa patients experienced a thrombus and 22% (n = 2) of FEIBA patients experienced a thrombus. Both rFVIIa and FEIBA reduced blood product usage in pediatric patients following cardiac procedures.

Clinical and Biochemical Assessments of Circulating B-Type Natriuretic Peptide as a Useful Marker in Pediatric Cardiac Patients

Background Although the left ventricle is the major site of BNP secretion in response to cardiac pressure or volume overload, the myocytes of both atria and ventricles secrete B- type natriuretic peptide (BNP). This study aimed to assess and compare the plasma levels of BNP in common pediatric cardiac diseases to clarify its pathophysiological role and evaluate its possible diagnostic and prognostic utility in pediatric patients with congenital heart disease (CHD), and heart failure (HF). Materials and Methods: The study is a prospective, case-control research including 131 pediatric patients selected from Pediatric Department of South Valley University Hospitals in Qena, Egypt, with a variety of cardiac diseases and 70 healthy controls. The patients were categorized into 4 groups: 61 newly diagnosed pediatric patients with CHD, 30 patients with HF, 20 pediatric patients with cardiomyopathy (CM), and 20 children with rheumatic heart disease (RHD). Clinical and echocardiographic assessments for the pediatric patients were performed. Bioassays of plasma BNP using commercially available ELISA assay kits were performed to the study the participants. Results: The median plasma BNP levels were significantly higher in the CHD, HF and CM groups than the RHD and control groups, with p Conclusion The validity of plasma BNP in diagnosing HF was significantly superior to its utility in predicting CHD among pediatric patients.

Risk Factors for Peri-Intubation Cardiac Arrest in Pediatric Cardiac Intensive Care Patients: A Multicenter Study.

Endotracheal intubation is associated with hemodynamic adverse events, including cardiac arrest, especially in patients with cardiac disease. There are only a few studies that have evaluated the rate of and risk factors for endotracheal intubation hemodynamic complications in critically ill pediatric patients. Although some of these studies have assessed hemodynamic complications during intubation in pediatric cardiac patients, the frequency of and risk factors for peri-intubation cardiac arrest have not been adequately described in high acuity cardiac patients. This study aims to describe the frequency of and risk factors for peri-intubation cardiac arrest in critically ill pediatric cardiac patients admitted to specialized cardiac ICUs. Multicenter retrospective cohort study. Three pediatric cardiac ICUs in the United States. Critically ill pediatric patients with congenital or acquired heart disease requiring endotracheal intubation. None. Endotracheal intubations performed in three cardiac ICUs between January 2015 and December 2017 were reviewed. Clinical variables-including data on patients, clinical providers, and procedure-were evaluated for their association with peri-intubation cardiac arrest. There was a total of 186 intubation events studied, occurring in 151 individual (index) patients. The rates of peri-intubation cardiac arrest and peri-intubation mortality in this cohort were 7% and 1.6%, respectively. Among those patients with moderate or severe systolic dysfunction of the systemic ventricle, peri-intubation cardiac arrest rate was 20.7%. Statistically significant risk factors for peri-intubation cardiac arrest included: significant systolic dysfunction of the systemic ventricle, pre-intubation hypotension, pre-intubation lactate elevation, lower pre-intubation pH, and documented oxygen desaturations (> 10%) during intubation procedure. Our most significant finding was a peri-intubation cardiac arrest rate which was much higher than previously published rates for both cardiac and noncardiac children who underwent endotracheal intubation in ICUs. Peri-intubation mortality was also high in our cohort. Regarding risk factors for peri-intubation arrest, significant systolic dysfunction of the systemic ventricle was strongly associated with cardiac arrest in this cohort.

Nurse-Implemented Goal-Directed Strategy to Improve Pain and Sedation Management in a Pediatric Cardiac ICU.

To assess the impact of a nurse-implemented goal-directed sedation strategy on patient care and nursing practice in a pediatric cardiac ICU. Quality improvement project with a pre-post interval measurement plan. Thirty-one bed pediatric cardiac ICU in a freestanding tertiary care children's hospital. Postoperative pediatric cardiac surgery patients. The implementation of cardiac-Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE), a nurse-implemented goal directed strategy to improve pain and sedation management in a pediatric cardiac ICU which included daily team discussion of the patient's trajectory of illness (acute, titration, or weaning phase), prescription of a sedation target score based on the patient's trajectory of illness, arousal assessments, and opioid and/or sedative titration. Withdrawal Assessment Scores were used to assess and manage iatrogenic withdrawal symptoms. Data related to opioid and sedation use, pain and sedation scores, and the occurrence and management of iatrogenic withdrawal symptoms were reviewed on 1,243 patients during four separate time periods: one pre-implementation and three discontinuous post-implementation time intervals. Patient age and complexity were consistent across the data collection periods. Post-implementation opioids and benzodiazepines use was reduced about 50% without a concomitant increase in the use of other sedative classes. Few post-intervention patients were discharged from the pediatric cardiac ICU or to home on methadone (pediatric cardiac ICU: pre 19% to post 3%; hospital: pre 12% to post 1.3%). Documentation of pain, sedation, and withdrawal scores became more consistent and nurses reported satisfaction with their patient's comfort management. The implementation of a nurse-driven goal-directed plan such as cardiac-RESTORE to manage pediatric cardiac ICU patient pain and sedation is possible, sustainable, and associated with reduced sedative and methadone use.

Randomized Pilot Trial of Acute Normovolemic Hemodilution in Pediatric Cardiac Surgery Patients.

Due to the substantial improvement in survival among pediatric patients undergoing congenital heart surgery, reducing early and long-term morbidity is becoming the major focus of care. Blood transfusion is associated with worse postoperative outcomes after cardiac surgery. Acute normovolemic hemodilution (ANH) is a blood conservation strategy that aims to reduce allogenic blood transfusion during cardiac surgery. However, there are scant data regarding its efficacy for pediatric cardiac surgery patients. We designed a single-center, controlled, randomized, pilot trial in patients between 6 and 36 months old undergoing pediatric heart surgery. Patients were equally assigned to undergo ANH prior to initiation of cardiopulmonary bypass or to be managed per usual care. The primary end point was the amount of blood product transfused perioperatively. Secondary end points were markers of morbidity: postoperative bleeding, hematocrit, inotropic agents use, intensive care unit, and hospital stay. The analysis was by intention-to-treat. Estimates of differences between groups are presented with 95% CIs. Twelve pediatric heart surgery patients were randomized to each group, ANH and usual care. Baseline characteristics were similar between groups. Acute normovolemic hemodilution implementation did not result in a reduction in the administration of blood product transfused (difference between ANH and usual care among patients transfused = -1.4 mL [-29.4 to 26.6], P = .92). Secondary end points were not different between groups. In this small trial of pediatric cardiac surgery patients, ANH as a strategy to reduce blood component therapy was safe; however, the study failed to show a reduction in perioperative transfusion or other postoperative outcomes.

Use of fenoldopam in children with congenital heart disease for acute increase in diuresis: descriptive study and insights into predictors of increased urine output

Introduction Fenoldopam is a dopamine D1 receptor agonist that is being increasingly used in pediatric cardiac patients for its presumed renoprotective effects and ability to increase urine output. There are very few studies that have investigated the effects of fenoldopam in pediatric cardiac patients to truly determine the effect on serum creatinine and urine output. This study set forth to determine the acute effects of creatinine on serum creatinine, serum blood urea nitrogen, urine output, and hemodynamics after the first few hours of infusion. Methods Pediatric patients under 18 years …

Risk Factors Associated with Perioperative Thrombosis in Infants Undergoing Cardiac Surgery

Introduction: Congenital heart surgery is often complicated by postoperative thrombosis which can lead to substantial morbidity and mortality(1). The estimated incidence of thrombosis in patients with congenital heart disease is 3-30% significantly more than other hospitalized children. Cardiac surgical patients less than 1 year of age have an even higher risk of postoperative thrombosis(1). Purpose: While the etiologies of thrombosis in pediatric cardiac surgery patients are complex, we sought to identify specific risk factors for thrombosis in neonates and infants who are at the highest risk …

Investigating the safety and opioid sparing effects of a scheduled regimen of Acetaminophen and NSAID in postoperative pediatric cardiac surgery patients

Investigating the safety and opioid sparing effects of a scheduled regimen of Acetaminophen and NSAID in postoperative pediatric cardiac surgery patients

Association between time of day and CPR quality as measured by CPR hemodynamics during pediatric in-hospital CPR

IntroductionPatients who suffer in-hospital cardiac arrest (IHCA) are less likely to survive if the arrest occurs during nighttime versus daytime. Diastolic blood pressure (DBP) as a measure of chest compression quality was associated with survival from pediatric IHCA. We hypothesized that DBP during CPR for IHCA is lower during nighttime versus daytime. MethodsThis is a secondary analysis of data collected from the Pediatric Intensive Care Quality of Cardiopulmonary Resuscitation Study. Pediatric or Pediatric Cardiac Intensive Care Unit patients who received chest compressions for ≥1 min and who had invasive arterial BP monitoring were enrolled. Nighttime was defined as 11:00PM to 6:59AM and daytime as 7:00AM until 10:59PM. Primary outcome was attainment of DBP ≥ 25 mmHg in infants <1 year and ≥30 mmHg in older children. Secondary outcomes were mean DBP, ROSC, and survival to hospital discharge. Univariable and multivariate analyses evaluated the relationships between time (nighttime vs. daytime) and outcomes. ResultsBetween July 1, 2013 and June 30, 2016, 164 arrests met all inclusion/exclusion criteria: 45(27%) occurred at nighttime and 119(73%) during daytime. Average DBPs achieved were not different between groups (DBP: nighttime 28.3 mmHg[25.3, 36.5] vs. daytime 29.6 mmHg[21.8, 38.0], p = 0.64). Relative risk of DBP threshold met during nighttime vs. daytime was 1.27, 95%CI [0.80, 1.98], p = 0.30. There was no significant nighttime vs. daytime difference in ROSC (28/45[62%] vs. 84/119[71%] p = 0.35) or survival to hospital discharge (16/45[36%] vs. 61/119[51%], p = 0.08). ConclusionsIn this cohort of pediatric ICU patients with IHCA, there was no significant difference in DBP during CPR between nighttime and daytime.

Relationship of preoperative NT-pro BNP with clinical, perioperative and prognostic markers in cardiac surgery: Preliminary study results

Objective: We aimed to define the relationship of preoperative N-terminal-pro-brain type natriuretic peptide (NT-pro-BNP) testing in routine practice of cardiac surgery with clinical, perioperative variables, surgical outcomes and complications in pediatric and adult cardiac surgery patients. In addition, we assessed relationship of NT-pro-BNP with EuroSCORE II in adult patients undergoing cardiac surgery. Methods: A total of 48 patients who underwent cardiac surgery in our institution were enrolled into this retrospective observational cohort study. According to age aspects pediatric (PG, n=20) and adult (AG, n=28) group of patients were separately evaluated. Each group further was categorized into two subgroups (group 1 and 2) on the basis of cut-off points of NT-pro-BNP level (430 and 250pg/ml in adults and children, respectively). Preoperative NT-pro- BNP was obtained from patients. Statistical tests were conducted to reveal differences in clinical and perioperative variables among NT-pro-BNP groups and relationship of the assay with baseline clinical and operative parameters, as well as postoperative outcomes. Results: In adults undergoing cardiac surgery, statistically significant differences were found between groups with low and high levels of NT-pro-BNP by NYHA classes (I to III, p˂0.001), body mass index (BMI) values (mean (SD) -31.7(3.15) vs 25.9 (3.8) kg/cm2, p=0.017), estimated glomerular filtration rate (eGFR) (111.4 (26.4) vs 77.9 (22.4) ml/min/1.73m2, p=0.036), moderately impaired renal function (20% vs 72.7%, p=0.049), need for inotropes (28.6% vs 86.7%, p=0.006), and mean EuroSCORE II (0.81 (0.19) vs 1.7 (0.5), p=0.008). There was the positive significant correlation of NT-pro-BNP levels with EuroSCORE II, NYHA class, need for inotropes, renal function and left ventricular (LV) function categories, while its negative correlation was found with BMI, LV ejection fraction and eGFR parameters. In PG – NT-pro-BNP was negatively correlated with age, body surface area, LV end-diastolic and end-systolic dimensions. Conclusion: In adult patients undergoing cardiac surgery, preoperative NT-pro-BNP level correlated well with several baseline and clinical-operative parameters, including BMI, renal and LV function, NYHA class, need for inotropes support, and EuroSCORE II. Further studies are needed to define its exact diagnostic and prognostic significance in pediatric patients.

The final reason paediatric Cardiac ICU patients require care prior to discharge to the floor: a single-centre survey.

To determine the Final ICU Need in the 24 hours prior to ICU discharge for children with cardiac disease by utilising a single-centre survey. A cross-sectional survey was utilised to determine Final ICU Need, which was categorised as "Cardiovascular", "Respiratory", "Feeding", "Sedation", "Systems Issue", or "Other" for each encounter. Survey responses were obtained from attending physicians who discharged children (≤18 years of age with ICU length of stay >24 hours) from the Cardiac ICU between April 2016 and July 2018. Survey response rate was 99% (n = 1073), with 667 encounters eligible for analysis. "Cardiovascular" (61%) and "Respiratory" (26%) were the most frequently chosen Final ICU Needs. From a multivariable mixed effects logistic regression model fitted to "Cardiovascular" and "Respiratory", operations with significantly reduced odds of having "Cardiovascular" Final ICU Need included Glenn palliation (p = 0.003), total anomalous pulmonary venous connection repair (p = 0.024), truncus arteriosus repair (p = 0.044), and vascular ring repair (p < 0.001). Short lengths of stay (<7.9 days) had significantly higher odds of "Cardiovascular" Final ICU Need (p < 0.001). "Cardiovascular" and "Respiratory" Final ICU Needs were also associated with provider and ICU discharge season. Final ICU Need is a novel metric to identify variations in Cardiac ICU utilisation and clinical trajectories. Final ICU Need was significantly influenced by benchmark operation, length of stay, provider, and season. Future applications of Final ICU Need include targeting quality and research initiatives, calibrating provider and family expectations, and identifying provider-level variability in care processes and mental models.

Vascular Access in Children With Congenital Heart Defects.

* Abbreviations: CVAD — : central venous access device miniMAGIC — : Michigan Appropriateness Guide for Intravenous Catheters in pediatrics VAD — : vascular access device Vascular access in pediatric cardiac patients is an inherently complex topic. Many clinicians struggle to understand the “plumbing,” let alone the implications that particular cardiovascular anatomic and physiologic derangements and our strategies of palliation have for children, both for the present and the future. Each choice a clinician makes regarding where and how to place a vascular access device (VAD), the length and diameter of the catheter, the surveillance and maintenance practices for the catheter, the duration the catheter is left indwelling, the types of therapies administered through the catheter, the blood sampled through the catheter, and the decision to remove the catheter can have major implications for a child’s future candidacy for additional catheterization and surgery. Simultaneously accounting for all of these factors can result in an incomprehensible morass. Through the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC), we have employed the use of an expert panel and the RAND Corporation and University of California, Los Angeles appropriateness methodology (which is similar to the approach that was used … Address correspondence to Ranjit Aiyagari, MD, Division of Pediatric Cardiology, C.S. Mott Children’s Hospital, 1540 E Hospital Dr, Ann Arbor, MI 48109-4204. E-mail: ranjita{at}umich.edu

Comparison of three autotransfusion devices for utilization in the pediatric population.

A device that may help attenuate the amount of homologous blood product given to pediatric cardiac surgical patients is the autotransfusion device. Three separate autotransfusion devices were selected for evaluation. The Sorin Xtra, Fresenius Continuous Autotransfusion System Plus (CATS*plus), and the Fresenius Continuous Autotransfusion System Smart (CATSmart) were evaluated based on the mechanical processes of each device, hematocrit value of the salvaged packed red cell product, time of processing, and the advantageous accessories with each device. Each of the autotransfusion devices were used to collect salvageable blood from the surgical field as well as to process residual blood from the cardiopulmonary bypass circuit after decannulation. The cell salvage process was performed in accordance with the manufacturer's instructions for use and the recommended settings for processing and washing. The Sorin Xtra device had the 55 mL bowl set up for all cases, while the Fresenius continuous autotransfusion systems utilized the standard disposable for each device. Each cell salvage device was employed during 30 pediatric cardiac surgery procedures, and data for each device, was broken down into four groups based on patient weight (0-10, 10-20, 20-40, and >40 kg). For all patient sizes, the Sorin Xtra tended to produce the greatest volume of cell saver product (55-825 mL) as compared to the CATS*plus and CATSmart devices (7-550 mL and 0-860 mL, respectively). The Continuous Autotransfusion System Smart tended to produce the highest hematocrit product, ranging from 44 to 81%. Through this evaluation, it was determined the continuous autotransfusion systems provided the highest hematocrit with the lowest recovered packed red cell volume, while the Sorin Xtra packed red cell product showed to have a lower hematocrit with a larger packed red cell volume. Each device proved effective within our pediatric population.

Pediatric Cardiac Critical Care Transport and Palliative Care: A Case Series.

To present our center's experience with terminal extubation in 3 palliative critical care home transports from the Pediatric Cardiac Intensive Unit. All cases were identified from our Cardiovascular intensive care unit ( CVICU). Patients were terminally ill children with no other surgical or medical option who were transported home between 2014 and 2018, for terminal extubation and end-of-life care according to their families' wishes. The patients were 7, 9 months, and 19 years; and they had very complex and chronic conditions. The families were approached by the CVICU staff during multidisciplinary meetings, where goals of care were established. Parental expectations were clarified, and palliative care team was involved, as well as home hospice was arranged pre transfer. The transfer process was discussed and all the needs were established. All patients had unstable medical conditions, with needs for transport for withdrawal of life support and death at home. Each case needed a highly trained team to support life while in transport. The need of these patients required coordination with home palliative care services, as well as community resources due to difficulty to get in their homes. Transportation of pediatric cardiac critical care patients for terminal extubation at home is a relatively infrequent practice. It is a feasible alternative for families seeking out of the hospital end-of-life care for their critically ill and technology dependent children. Our single-center experience supports the need for development of formal programs for end-of-life critical care transports.

Quantitative cardiac magnetic resonance T2 imaging offers ability to non-invasively predict acute allograft rejection in children.

Monitoring for acute allograft rejection improves outcomes after cardiac transplantation. Endomyocardial biopsy is the gold standard test defining rejection, but carries risk and has limitations. Cardiac magnetic resonance T2 mapping may be able to predict rejection in adults, but has not been studied in children. Our aim was to evaluate T2 mapping in identifying paediatric cardiac transplant patients with acute rejection. Eleven paediatric transplant patients presenting 18 times were prospectively enrolled for non-contrast cardiac magnetic resonance at 1.5 T followed by endomyocardial biopsy. Imaging included volumetry, flow, and T2 mapping. Regions of interest were manually selected on the T2 maps using the middle-third technique in the left ventricular septal and lateral wall in a short-axis and four-chamber slice. Mean and maximum T2 values were compared with Student's t-tests analysis. Five cases of acute rejection were identified in three patients, including two cases of grade 2R on biopsy and three cases of negative biopsy treated for clinical symptoms attributed to rejection (new arrhythmia, decreased exercise capacity). A monotonic trend between increasing T2 values and higher biopsy grades was observed: grade 0R T2 53.4 ± 3 ms, grade 1R T2 54.5 ms ± 3 ms, grade 2R T2 61.3 ± 1 ms. The five rejection cases had significantly higher mean T2 values compared to cases without rejection (58.3 ± 4 ms versus 53 ± 2 ms, p = 0.001). Cardiac magnetic resonance with quantitative T2 mapping may offer a non-invasive method for screening paediatric cardiac transplant patients for acute allograft rejection. More data are needed to understand the relationship between T2 and rejection in children.

Hyperlactatemia: An Update on Postoperative Lactate.

While hyperlactatemia in postoperative cardiac surgery patients was once believed to solely reflect hypoperfusion, either from the accumulated "oxygen debt" during bypass or ongoing inadequate perfusion, our understanding of lactate generation, clearance, and management has evolved. A contemporary understanding of lactate balance is critical to the management of the postoperative patient with hyperlactatemia. In this review, we summarize the current understanding of lactate metabolism in pediatric patients following cardiac surgery and highlight two types of hyperlactatemia: type A, which is secondary to inadequate oxygen delivery and tissue hypoxia, and type B, which in postoperative pediatric cardiac surgery patients largely reflects increased glycolysis driven by the stress response. Both types may coexist; thus, it is imperative that providers first assess the patient for evidence of hypoperfusion. In patients with evidence of adequate perfusion, a type B component is often associated with a concomitant balanced (normal anion gap) metabolic acidosis and hyperglycemia. These patients will benefit from a more nuanced approach to their type B hyperlactatemia, as many will have a benign course and may be managed expectantly.