Multisite near infrared spectroscopy (NIRS) monitoring during pediatric cardiopulmonary bypass (C... more Multisite near infrared spectroscopy (NIRS) monitoring during pediatric cardiopulmonary bypass (CPB) has not been extensively validated. Although it might be rational to explore regional tissue saturation at different body sites (namely brain, kidney, upper body, lower body), conflicting results are currently provided by experience in children. The aim of our study was to evaluate absolute values of multisite NIRS saturation during CPB in a cohort of infants undergoing pediatric cardiac surgery to describe average differences between cerebral, renal, upper body (arm), and lower body (thigh) regional saturation. Furthermore, the correlation between cerebral NIRS and cardiac index (CI) at CPB weaning was evaluated. Twenty-five infants were enrolled: their median weight, age, and body surface area were 3.9 (3.3-6) kg, 111 (47-203) days, and 0.24 (0.22-0.33) m(2) , respectively. Median Aristotle score was 8 (6-10), and vasoactive inotropic score at CPB weaning was 16 (14-25). A total of 17 430 data points were recorded by each sensor: two-way ANOVA showed that time (P < 0.0001) and site (P = 0.0001) significantly affected variations of NIRS values: however, if cerebral NIRS values are excluded, sensor site is no more significant (P = 0.184 in the no circulatory arrest [noCA] group and P = 0.42 in the circulatory arrest [CA] group). Analysis of NIRS saturation changes over time showed that, at all sites, average NIRS values increased after CPB start, even if the increase of cerebral saturation was less intense than other sites (P < 0.0001). Detailed analysis of interaction between site of NIRS measurement and time point showed that cerebral NIRS (ranging from 65 to 75%) was always significantly lower than that of other channels (P < 0.0001) that tended to be in the range of oversaturation (80-90%), especially during the CPB phase. Average cerebral NIRS values of patients who did not undergo circulatory arrest (CA) during CPB, 10 min after CPB weaning, were associated with average CI values with a significant correlation (r = 0.7, P = 0.003). In conclusion, during CPB, cerebral NIRS values are expected to remain constantly lower than somatic sensors, which instead tend to show similar elevated saturations, regardless of their position. Based on these results, positioning of noncerebral NIRS sensors during CPB without CA may be questioned.
To evaluate diagnostic and prognostic significance of neutrophil gelatinase-associated lipocalin ... more To evaluate diagnostic and prognostic significance of neutrophil gelatinase-associated lipocalin during extracorporeal membrane oxygenation in children with congenital heart disease. Prospective observational study. Pediatric cardiac intensive care unit. Ten pediatric patients with congenital heart disease requiring venoarterial extracorporeal membrane oxygenation for postoperative cardiorespiratory support were prospectively enrolled. None. Five patients were successfully weaned from extracorporeal membrane oxygenation and survived to intensive care unit discharge; five children died during extracorporeal therapy or within 12 hrs from extracorporeal membrane oxygenation stop. Continuous renal replacement therapy after extracorporeal membrane oxygenation start was indicated for three patients. When patients on continuous venovenous hemofiltration were compared with patients not on continuous venovenous hemofiltration, diuretic administration was lower (1.5 vs. 10 mg/kg/day), extracorporeal membrane oxygenation duration was longer (7 [range, 6-14]) vs. 4 [range, 3-8] days), and survival decreased from 60% (four of seven) to 33% (one of three). Neutrophil gelatinase-associated lipocalin levels were higher at the first extracorporeal membrane oxygenation day in patients who underwent continuous venovenous hemofiltration, 285 (range, 181-513) vs. 130 (range, 81-277) ng/mL, in patients who did not undergo continuous venovenous hemofiltration (p = .045). Neutrophil gelatinase-associated lipocalin levels remained higher among patients on continuous venovenous hemofiltration than others throughout the examined extracorporeal membrane oxygenation period (p = .0007), whereas creatinine levels tended to be equivalent between the two groups (p = .38). However, a trend toward increasing neutrophil gelatinase-associated lipocalin levels was noticed also in patients not on continuous venovenous hemofiltration. Neutrophil gelatinase-associated lipocalin levels at the first extracorporeal membrane oxygenation day may have predictive value for continuous venovenous hemofiltration. During the course of extracorporeal membrane oxygenation support, creatinine levels were normalized in patients with acute kidney injury undergoing continuous venovenous hemofiltration; in these patients, neutrophil gelatinase-associated lipocalin levels may provide further information on kidney injury.
The aim of this article is to describe the epidemiology and factors associated with acute neurolo... more The aim of this article is to describe the epidemiology and factors associated with acute neurologic injury in neonates with congenital heart disease (CHD) undergoing extracorporeal membrane oxygenation (ECMO). It is a retrospective cohort study. Multi-institutional data for purposes of this study were obtained from the extracorporeal life support organization registry Neonates with CHD supported with ECMO during 2005-2010. Of 1,898 neonates with CHD supported with ECMO, 273 (14%) had neurologic injury. Birth weight less than 3 kg (odds ratio [OR]: 1.5; 95% confidence intervals [CI]: 1.1-1.9), pre-ECMO blood pH ≤ 7.15 (OR: 1.5, 95% CI: 1.1-2.1) need for cardiopulmonary resuscitation before ECMO (OR: 1.7, 95% CI: 1.5-2.0) increased neurologic injury. In-hospital mortality was higher in patients with neurologic injury compared with those without (73% vs. 53%; p < 0.001). Neonates with CHD undergoing ECMO are highly vulnerable to acute neurologic injury regardless of cardiac lesion-specific physiology or the occurrence of cardiac surgery. The incidence of neurologic injuries in this population is higher in sicker patients. Severity of illness should therefore become the main target for improvement. Timely deployment of ECMO may therefore influence the development of ECMO complications.
World Journal for Pediatric and Congenital Heart Surgery, 2010
The aim of this study was to evaluate the safety and the efficacy of levosimendan, a novel calciu... more The aim of this study was to evaluate the safety and the efficacy of levosimendan, a novel calcium sensitizer agent, on postoperative hemodynamic and metabolic parameters of neonates affected by single ventricle anatomy. Twenty consecutive neonates scheduled for the Norwood procedure with Blalock Taussig shunt were prospectively enrolled. All patients received an infusion of levosimendan at 0.1 μg/kg/min commencing 24 hours before surgery, and the infusion was continued for 48 hours after surgery. No side effects (intolerance to the drug, hypotension, arrhythmias) were shown. A median inotropic score (IS) of 37 was necessary to maintain a mean arterial pressure between 45 and 50 mm Hg at intensive care unit (ICU) admission: IS was significantly reduced after 72 hours (P < .05). Brain natriuretic peptide values decreased significantly from 1210 to 459 pg/mL in 72 hours (P < .05). Median SvO2 increased significantly from 38% to 59% during the evaluated period (P < .05). Cerebral near-infrared spectroscopy values were close to 40% at ICU admission with a significant stable increase to 50% after 12 hours (P < .05). Median lactate level was 13 mmol/L at ICU admission but showed a trend to a rapid and significant decrease after 12 hours (P < .05). Median urine output was surprisingly elevated, always remaining between 5.2 and 6.2 mL/kg/h throughout the postoperative period. Survival rate was 85% at 30 days (17/20 patients) and 75% (15/20) at hospital discharge. Levosimendan infusion in a cohort of neonates with univentricular anatomy was safe and potentially beneficial on postoperative hemodynamic and metabolic parameters.
The care of acute kidney injury (AKI) in critically ill children shares several features with adu... more The care of acute kidney injury (AKI) in critically ill children shares several features with adult AKI with some critical distinctions: in both settings, however, the exact identification of renal dysfunction, in-depth knowledge of disparate risk factors and patient-specific management are the primary targets in order to provide optimal care. This article will specifically review recent work published on pediatric AKI about definition and epidemiology, the possible etiologies in specific conditions, and the newest laboratory investigations necessary to diagnose AKI severity. A short description of pediatric renal replacement therapies and their potential application to extracorporeal membrane oxygenation will also be described.
ABSTRACT A total of 60 patients less than 1 year old were enrolled in this study: 30 received fen... more ABSTRACT A total of 60 patients less than 1 year old were enrolled in this study: 30 received fenoldopam (group F) during CPB at the dose of 1 mcg/kg/min and 30 received placebo (group P). Differences in urine output, creatinine levels, baseline biomarkers levels, fluid balance and hemodynamic parameters were not present. Serum and urinary levels of neutrophil gelatinase associated lipocalin (sNGAL and uNGAL) and and cystatin-C (sCYS-C and uCYS-C) levels at the end of surgery (t1) and 12 hours after (t2) in group F vs group P were: sNGAL t1 88±37 ng/ml vs 107±42 ng/ml, sNGAL t2 88±44 ng/ml vs 107±42 ng/ml, uNGAL t1 22±29 ng/ml vs 60±71 ng/ml, uNGAL t2 15±13 ng/ml vs 34±59 ng/ml, sCYS-C t1 0.92±0.3 mg/l vs 1.06±0.2 mg/l, sCYS-C t2 1.126±0.3 mg/l vs 1.38±0.35 mg/l, uCYS-C t1 0.01±0.1 mg/l vs 0.196±0.34 mg/l, uCYS-C t2 0.05±0.005 mg/l vs 0.075±0.05 mg/l (always, p< 0.05). Systemic vascular resistances were 309±102 dyne*sec/cm−5 in group F vs 421±164 dyne*sec/cm−5 in group P (p=0.02). Oxygen delivery (DO2) in group F was 2474±878 ml O2/min vs 1818±797 ml O2/min in group P (p=0.02). Finally, a significant reduction in furosemide boluses (1 mg/kg) was observed in group F (OR 0.3, CI 95% 0.1-0.9, p: 0.03).Conclusions: The treatment with high-dose fenoldopam during CPB in pediatric patients undergoing cardiac surgery for CHD significantly decreased serum and urinary levels of NGAL and CYS-C, optimized diuretics administration and improved perfusion during CPB.
To assess the ability of a single whole blood neutrophil gelatinase-associated lipocalin measurem... more To assess the ability of a single whole blood neutrophil gelatinase-associated lipocalin measurement in predicting acute kidney injury occurrence, its severity, and the need for postoperative renal replacement therapy after pediatric cardiac surgery. Single-center prospective cross-sectional study. Tertiary care pediatric cardiac intensive care unit. Consecutive children <1 yr old with congenital heart diseases undergoing cardiac surgery with cardiopulmonary bypass. None. Neutrophil gelatinase-associated lipocalin levels were measured after pediatric cardiac intensive care unit admission. Pediatric score indicating level of renal damage by Risk, Injury, Failure, Loss of function and End-stage kidney disease (pRIFLE) was used as the reference method. Acute kidney injury was diagnosed in 90 (56%) of the 160 enrolled patients. The number of abnormal neutrophil gelatinase-associated lipocalin samples (above the cutoff level of 150 ng/mL) was 12 over 90 (13%) in acute kidney injury population and 6 over 70 in non-acute kidney injury patients (8%) (odds ratio 1.6; 95% confidence interval 0.6-4.7; p = .31). Sensitivity of neutrophil gelatinase-associated lipocalin for acute kidney injury detection was 0.13 and specificity 0.91. The number of patients with abnormal neutrophil gelatinase-associated lipocalin samples was not significantly different within pediatric score indicating level of renal damage by pRIFLE (p = .69); furthermore, we found abnormal neutrophil gelatinase-associated lipocalin levels in 4 (30%) over 13 renal replacement therapy patients and in 14 (10%) over 133 children without renal replacement therapy need (odds ratio 4.2; 95% confidence interval 1.2-10.2; p = .02). Mean cross-clamp time (p = .28), inotropic score (p = .19), surgical risk score (p = .3), mean length of mechanical ventilation (p = .48), and pediatric cardiac intensive care unit stay (p = .57) did not significantly differ between children with abnormal and normal neutrophil gelatinase-associated lipocalin values. Neutrophil gelatinase-associated lipocalin measured at pediatric cardiac intensive care unit arrival does not accurately predict acute kidney injury diagnosis, according to pediatric score indicating level of renal damage by pRIFLE classification. In these patients, neutrophil gelatinase-associated lipocalin might be helpful for renal replacement therapy prediction.
Proulx and colleagues (1) recently conducted a comprehensive review on the PiCCO system for cardi... more Proulx and colleagues (1) recently conducted a comprehensive review on the PiCCO system for cardiac output (CO) measurement, whose technology provides continuous CO calculation based on the analysis of the arterial pressure waveform calibrated after ...
Modified ultrafiltration is commonly used in pediatric cardiac surgery. Although its clinical ben... more Modified ultrafiltration is commonly used in pediatric cardiac surgery. Although its clinical benefits are currently debated, modified ultrafiltration has proved to improve mean arterial pressure in the first postoperative hours. Aim of our study was to measure cardiac index, stroke volume index, and mean arterial pressure modification before and after modified ultrafiltration by means of Pressure Recording Analytical Method. Single-center prospective observational cohort study. Pediatric cardiac surgery operating room. Children below 20 kg that are included in the "pediatric" mode of Pressure Recording Analytical Method. Forty patients were enrolled in this study. Median age, weight, and body surface area at surgery were 3 months (interquartile range, 10 days to 3.5 yr), 5.6 (3.1-15) kg, and 0.31 (0.21-0.56), respectively. During the modified ultrafiltration procedure, a median volume of 17 mL/kg (11-25) was ultrafiltered and a median volume of 11 mL/kg (6-17) was reinfused with a median final modified ultrafiltration balance of -0.15 mL/kg (-4.0 to 0.1). By univariate analyses, there was a 10% increase in postmodified ultrafiltration mean, systolic and diastolic pressures (p = 0.01), stroke volume index (p = 0.02), and cardiac index (p = 0.001) without significant changes in heart rate, central (left and right) venous pressures, stroke volume variation, and inotropic score. By multivariate analysis, when controlling for cardiopulmonary bypass time and age at surgery, cardiac index variation was independently associated with lower preoperative body surface area (beta coefficient -5.5, p = 0.04). According to Pressure Recording Analytical Method assessment, modified ultrafiltration acutely improves myocardial function, as shown by a 10% increase of systemic arterial pressure, stroke volume index, and cardiac index. This effect is more pronounced in smaller sized patients.
Septic shock is an important cause of morbidity and mortality in critically ill children. Early m... more Septic shock is an important cause of morbidity and mortality in critically ill children. Early mortality usually results from resistant hypotension with progressive acidosis refractory to fluid resuscitation and high-dose catecholamine administration. Findings have shown that ...
Bleeding during and after cardiac surgery is a major issue in pediatric patients. A prospective c... more Bleeding during and after cardiac surgery is a major issue in pediatric patients. A prospective cohort study was conducted to evaluate the effect of a commercially available prothrombin complex (Confidex) administered in cardiac surgery after weaning from cardiopulmonary bypass of infants with nonsurgical bleeding. In this study, 14 patients younger than 1 year received a Confidex bolus and were matched with 11 patients of a similar age who did not receive the drug. The preoperative coagulation profile was similar in the two groups. No side effects, including anaphylaxis or thrombotic events, were observed. The numbers of units of packed red blood cells and fresh frozen plasma administered both intra- and postoperatively were similar. The postoperative coagulation examination results and thromboelastographic parameters did not differ significantly between the two groups. However, the Confidex patients bled significantly less than the control subjects during the first 24 postoperative hours. The median volume of drained blood was 0.0 ml/kg h (range 0-1.9 ml/kg h) compared with 1.9 ml/kg h (range 1-3 ml/kg h) (p = 0.009). At least one unit of packed red blood cells in the postoperative phase was required by 2 patients (14 %) in the Confidex group and six patients (54 %) in the control group (odds ratio [OR], 0.13; 95 % confidence interval [CI], 0.02-0.9; p = 0.03). The median duration of mechanical ventilation was 3 days (range 2-4 days) in the Confidex group and 4 days (range 0-8 days) in the control group (p = 0.66). The median stay in the intensive care unit was 6 days (range 5-9 days) in the Confidex group and 7 days (range 4-12 days) in the control group (p = 0.88). The use of Confidex for infants undergoing cardiac surgery was safe and effective. It reduced postoperative bleeding and allowed fewer units of packed red blood cells to be infused in the postoperative phase without major side effects.
It is currently uncertain which hemodynamic monitoring device reliably measures stroke volume and... more It is currently uncertain which hemodynamic monitoring device reliably measures stroke volume and tracks cardiac output changes in pediatric cardiac surgery patients. To evaluate the difference between stroke volume index (SVI) measured by pressure recording analytical method (PRAM) and bioreactance and their ability to track changes after a therapeutic intervention. A single-center prospective observational cohort study in children undergoing cardiac surgery with cardiopulmonary bypass (CPB) was conducted. Twenty children below 20 kg with median (interquartile range) weight of 5.3 kg (4.1-7.8) and age of 6 months (3-20) were enrolled. Data were collected after anesthesia induction, at the end of CPB, before fluid administration and after fluid administration. Overall, median-IQR PRAM SVI values (23 ml·m(-2), 19-27) were significantly higher than bioreactance SVI (15 ml·m(-2), 12-25, P = 0.0001). Correlation (r(2) ) between the two methods was 0.15 (P = 0.0003). The mean difference between the measurements (bias) was 5.7 ml·m(-2) with a standard deviation of 9.6 (95% limits of agreement ranged from -13 to 24 ml·m(-2)). Percentage error was 91.7%. Baseline SVI appeared to be similar, but PRAM SVI was systematically greater than bioreactance thereafter, with the highest gap after the fluid loading phase: 13 (12-18) ml·m(-2) vs. 23 (19-25) ml·m(-2), respectively, P = 0.0013. A multivariable regression model showed that a significant independent inverse correlation with patients' body weight predicted the CI difference between the two methods after fluid challenge (β coefficient -0.12, P = 0.013). Pressure recording analytical method and bioreactance provided similar SVI estimation at stable hemodynamic conditions, while bioreactance SVI values appeared significantly lower than PRAM at the end of CPB and after fluid replacement.
To evaluate the safety and efficacy of levosimendan in neonates with congenital heart disease und... more To evaluate the safety and efficacy of levosimendan in neonates with congenital heart disease undergoing cardiac surgery with cardiopulmonary bypass (CPB). Neonates undergoing risk-adjusted classification for congenital heart surgery (RACHS) 3 and 4 procedures were randomized to receive either a 72 h continuous infusion of 0.1 μg/kg/min levosimendan or standard post-CPB inotrope infusion. Sixty-three patients (32 cases and 31 controls) were recruited. There were no differences between groups regarding demographic and baseline clinical data. No side effects were observed. There were no significant differences in mortality (1 vs. 3 patients, p = 0.35), length of mechanical ventilation (5.9 ± 5 vs. 6.9 ± 8 days, p = 0.54), and pediatric cardiac intensive care unit (PCICU) stay (11 ± 8 vs. 14 ± 14 days, p = 0.26). Low cardiac output syndrome occurred in 37 % of levosimendan patients and in 61 % of controls (p = 0.059, OR 0.38, 95 % CI 0.14-1.0). Postoperative heart rate, with a significant difference at 6 (p = 0.008), 12 (p = 0.037), and 24 h (p = 0.046), and lactate levels, with a significant difference at PCICU admission (p = 0.015) and after 6 h (p = 0.048), were lower in the levosimendan group. Inotropic score was significantly lower in the levosimendan group at PCICU admission, after 6 h and after 12 h, (p < 0.0001). According to multivariate analysis, a lower lactate level 6 h after PCICU admission was independently associated with levosimendan administration after correction for CPB time and the need for deep hypothermic circulatory arrest. Levosimendan infused in neonates undergoing cardiac surgery was well tolerated with a potential benefit of levosimendan on postoperative hemodynamic and metabolic parameters of RACHS 3-4 neonates.
Multisite near infrared spectroscopy (NIRS) monitoring during pediatric cardiopulmonary bypass (C... more Multisite near infrared spectroscopy (NIRS) monitoring during pediatric cardiopulmonary bypass (CPB) has not been extensively validated. Although it might be rational to explore regional tissue saturation at different body sites (namely brain, kidney, upper body, lower body), conflicting results are currently provided by experience in children. The aim of our study was to evaluate absolute values of multisite NIRS saturation during CPB in a cohort of infants undergoing pediatric cardiac surgery to describe average differences between cerebral, renal, upper body (arm), and lower body (thigh) regional saturation. Furthermore, the correlation between cerebral NIRS and cardiac index (CI) at CPB weaning was evaluated. Twenty-five infants were enrolled: their median weight, age, and body surface area were 3.9 (3.3-6) kg, 111 (47-203) days, and 0.24 (0.22-0.33) m(2) , respectively. Median Aristotle score was 8 (6-10), and vasoactive inotropic score at CPB weaning was 16 (14-25). A total of 17 430 data points were recorded by each sensor: two-way ANOVA showed that time (P < 0.0001) and site (P = 0.0001) significantly affected variations of NIRS values: however, if cerebral NIRS values are excluded, sensor site is no more significant (P = 0.184 in the no circulatory arrest [noCA] group and P = 0.42 in the circulatory arrest [CA] group). Analysis of NIRS saturation changes over time showed that, at all sites, average NIRS values increased after CPB start, even if the increase of cerebral saturation was less intense than other sites (P < 0.0001). Detailed analysis of interaction between site of NIRS measurement and time point showed that cerebral NIRS (ranging from 65 to 75%) was always significantly lower than that of other channels (P < 0.0001) that tended to be in the range of oversaturation (80-90%), especially during the CPB phase. Average cerebral NIRS values of patients who did not undergo circulatory arrest (CA) during CPB, 10 min after CPB weaning, were associated with average CI values with a significant correlation (r = 0.7, P = 0.003). In conclusion, during CPB, cerebral NIRS values are expected to remain constantly lower than somatic sensors, which instead tend to show similar elevated saturations, regardless of their position. Based on these results, positioning of noncerebral NIRS sensors during CPB without CA may be questioned.
To evaluate diagnostic and prognostic significance of neutrophil gelatinase-associated lipocalin ... more To evaluate diagnostic and prognostic significance of neutrophil gelatinase-associated lipocalin during extracorporeal membrane oxygenation in children with congenital heart disease. Prospective observational study. Pediatric cardiac intensive care unit. Ten pediatric patients with congenital heart disease requiring venoarterial extracorporeal membrane oxygenation for postoperative cardiorespiratory support were prospectively enrolled. None. Five patients were successfully weaned from extracorporeal membrane oxygenation and survived to intensive care unit discharge; five children died during extracorporeal therapy or within 12 hrs from extracorporeal membrane oxygenation stop. Continuous renal replacement therapy after extracorporeal membrane oxygenation start was indicated for three patients. When patients on continuous venovenous hemofiltration were compared with patients not on continuous venovenous hemofiltration, diuretic administration was lower (1.5 vs. 10 mg/kg/day), extracorporeal membrane oxygenation duration was longer (7 [range, 6-14]) vs. 4 [range, 3-8] days), and survival decreased from 60% (four of seven) to 33% (one of three). Neutrophil gelatinase-associated lipocalin levels were higher at the first extracorporeal membrane oxygenation day in patients who underwent continuous venovenous hemofiltration, 285 (range, 181-513) vs. 130 (range, 81-277) ng/mL, in patients who did not undergo continuous venovenous hemofiltration (p = .045). Neutrophil gelatinase-associated lipocalin levels remained higher among patients on continuous venovenous hemofiltration than others throughout the examined extracorporeal membrane oxygenation period (p = .0007), whereas creatinine levels tended to be equivalent between the two groups (p = .38). However, a trend toward increasing neutrophil gelatinase-associated lipocalin levels was noticed also in patients not on continuous venovenous hemofiltration. Neutrophil gelatinase-associated lipocalin levels at the first extracorporeal membrane oxygenation day may have predictive value for continuous venovenous hemofiltration. During the course of extracorporeal membrane oxygenation support, creatinine levels were normalized in patients with acute kidney injury undergoing continuous venovenous hemofiltration; in these patients, neutrophil gelatinase-associated lipocalin levels may provide further information on kidney injury.
The aim of this article is to describe the epidemiology and factors associated with acute neurolo... more The aim of this article is to describe the epidemiology and factors associated with acute neurologic injury in neonates with congenital heart disease (CHD) undergoing extracorporeal membrane oxygenation (ECMO). It is a retrospective cohort study. Multi-institutional data for purposes of this study were obtained from the extracorporeal life support organization registry Neonates with CHD supported with ECMO during 2005-2010. Of 1,898 neonates with CHD supported with ECMO, 273 (14%) had neurologic injury. Birth weight less than 3 kg (odds ratio [OR]: 1.5; 95% confidence intervals [CI]: 1.1-1.9), pre-ECMO blood pH ≤ 7.15 (OR: 1.5, 95% CI: 1.1-2.1) need for cardiopulmonary resuscitation before ECMO (OR: 1.7, 95% CI: 1.5-2.0) increased neurologic injury. In-hospital mortality was higher in patients with neurologic injury compared with those without (73% vs. 53%; p < 0.001). Neonates with CHD undergoing ECMO are highly vulnerable to acute neurologic injury regardless of cardiac lesion-specific physiology or the occurrence of cardiac surgery. The incidence of neurologic injuries in this population is higher in sicker patients. Severity of illness should therefore become the main target for improvement. Timely deployment of ECMO may therefore influence the development of ECMO complications.
World Journal for Pediatric and Congenital Heart Surgery, 2010
The aim of this study was to evaluate the safety and the efficacy of levosimendan, a novel calciu... more The aim of this study was to evaluate the safety and the efficacy of levosimendan, a novel calcium sensitizer agent, on postoperative hemodynamic and metabolic parameters of neonates affected by single ventricle anatomy. Twenty consecutive neonates scheduled for the Norwood procedure with Blalock Taussig shunt were prospectively enrolled. All patients received an infusion of levosimendan at 0.1 μg/kg/min commencing 24 hours before surgery, and the infusion was continued for 48 hours after surgery. No side effects (intolerance to the drug, hypotension, arrhythmias) were shown. A median inotropic score (IS) of 37 was necessary to maintain a mean arterial pressure between 45 and 50 mm Hg at intensive care unit (ICU) admission: IS was significantly reduced after 72 hours (P < .05). Brain natriuretic peptide values decreased significantly from 1210 to 459 pg/mL in 72 hours (P < .05). Median SvO2 increased significantly from 38% to 59% during the evaluated period (P < .05). Cerebral near-infrared spectroscopy values were close to 40% at ICU admission with a significant stable increase to 50% after 12 hours (P < .05). Median lactate level was 13 mmol/L at ICU admission but showed a trend to a rapid and significant decrease after 12 hours (P < .05). Median urine output was surprisingly elevated, always remaining between 5.2 and 6.2 mL/kg/h throughout the postoperative period. Survival rate was 85% at 30 days (17/20 patients) and 75% (15/20) at hospital discharge. Levosimendan infusion in a cohort of neonates with univentricular anatomy was safe and potentially beneficial on postoperative hemodynamic and metabolic parameters.
The care of acute kidney injury (AKI) in critically ill children shares several features with adu... more The care of acute kidney injury (AKI) in critically ill children shares several features with adult AKI with some critical distinctions: in both settings, however, the exact identification of renal dysfunction, in-depth knowledge of disparate risk factors and patient-specific management are the primary targets in order to provide optimal care. This article will specifically review recent work published on pediatric AKI about definition and epidemiology, the possible etiologies in specific conditions, and the newest laboratory investigations necessary to diagnose AKI severity. A short description of pediatric renal replacement therapies and their potential application to extracorporeal membrane oxygenation will also be described.
ABSTRACT A total of 60 patients less than 1 year old were enrolled in this study: 30 received fen... more ABSTRACT A total of 60 patients less than 1 year old were enrolled in this study: 30 received fenoldopam (group F) during CPB at the dose of 1 mcg/kg/min and 30 received placebo (group P). Differences in urine output, creatinine levels, baseline biomarkers levels, fluid balance and hemodynamic parameters were not present. Serum and urinary levels of neutrophil gelatinase associated lipocalin (sNGAL and uNGAL) and and cystatin-C (sCYS-C and uCYS-C) levels at the end of surgery (t1) and 12 hours after (t2) in group F vs group P were: sNGAL t1 88±37 ng/ml vs 107±42 ng/ml, sNGAL t2 88±44 ng/ml vs 107±42 ng/ml, uNGAL t1 22±29 ng/ml vs 60±71 ng/ml, uNGAL t2 15±13 ng/ml vs 34±59 ng/ml, sCYS-C t1 0.92±0.3 mg/l vs 1.06±0.2 mg/l, sCYS-C t2 1.126±0.3 mg/l vs 1.38±0.35 mg/l, uCYS-C t1 0.01±0.1 mg/l vs 0.196±0.34 mg/l, uCYS-C t2 0.05±0.005 mg/l vs 0.075±0.05 mg/l (always, p< 0.05). Systemic vascular resistances were 309±102 dyne*sec/cm−5 in group F vs 421±164 dyne*sec/cm−5 in group P (p=0.02). Oxygen delivery (DO2) in group F was 2474±878 ml O2/min vs 1818±797 ml O2/min in group P (p=0.02). Finally, a significant reduction in furosemide boluses (1 mg/kg) was observed in group F (OR 0.3, CI 95% 0.1-0.9, p: 0.03).Conclusions: The treatment with high-dose fenoldopam during CPB in pediatric patients undergoing cardiac surgery for CHD significantly decreased serum and urinary levels of NGAL and CYS-C, optimized diuretics administration and improved perfusion during CPB.
To assess the ability of a single whole blood neutrophil gelatinase-associated lipocalin measurem... more To assess the ability of a single whole blood neutrophil gelatinase-associated lipocalin measurement in predicting acute kidney injury occurrence, its severity, and the need for postoperative renal replacement therapy after pediatric cardiac surgery. Single-center prospective cross-sectional study. Tertiary care pediatric cardiac intensive care unit. Consecutive children <1 yr old with congenital heart diseases undergoing cardiac surgery with cardiopulmonary bypass. None. Neutrophil gelatinase-associated lipocalin levels were measured after pediatric cardiac intensive care unit admission. Pediatric score indicating level of renal damage by Risk, Injury, Failure, Loss of function and End-stage kidney disease (pRIFLE) was used as the reference method. Acute kidney injury was diagnosed in 90 (56%) of the 160 enrolled patients. The number of abnormal neutrophil gelatinase-associated lipocalin samples (above the cutoff level of 150 ng/mL) was 12 over 90 (13%) in acute kidney injury population and 6 over 70 in non-acute kidney injury patients (8%) (odds ratio 1.6; 95% confidence interval 0.6-4.7; p = .31). Sensitivity of neutrophil gelatinase-associated lipocalin for acute kidney injury detection was 0.13 and specificity 0.91. The number of patients with abnormal neutrophil gelatinase-associated lipocalin samples was not significantly different within pediatric score indicating level of renal damage by pRIFLE (p = .69); furthermore, we found abnormal neutrophil gelatinase-associated lipocalin levels in 4 (30%) over 13 renal replacement therapy patients and in 14 (10%) over 133 children without renal replacement therapy need (odds ratio 4.2; 95% confidence interval 1.2-10.2; p = .02). Mean cross-clamp time (p = .28), inotropic score (p = .19), surgical risk score (p = .3), mean length of mechanical ventilation (p = .48), and pediatric cardiac intensive care unit stay (p = .57) did not significantly differ between children with abnormal and normal neutrophil gelatinase-associated lipocalin values. Neutrophil gelatinase-associated lipocalin measured at pediatric cardiac intensive care unit arrival does not accurately predict acute kidney injury diagnosis, according to pediatric score indicating level of renal damage by pRIFLE classification. In these patients, neutrophil gelatinase-associated lipocalin might be helpful for renal replacement therapy prediction.
Proulx and colleagues (1) recently conducted a comprehensive review on the PiCCO system for cardi... more Proulx and colleagues (1) recently conducted a comprehensive review on the PiCCO system for cardiac output (CO) measurement, whose technology provides continuous CO calculation based on the analysis of the arterial pressure waveform calibrated after ...
Modified ultrafiltration is commonly used in pediatric cardiac surgery. Although its clinical ben... more Modified ultrafiltration is commonly used in pediatric cardiac surgery. Although its clinical benefits are currently debated, modified ultrafiltration has proved to improve mean arterial pressure in the first postoperative hours. Aim of our study was to measure cardiac index, stroke volume index, and mean arterial pressure modification before and after modified ultrafiltration by means of Pressure Recording Analytical Method. Single-center prospective observational cohort study. Pediatric cardiac surgery operating room. Children below 20 kg that are included in the "pediatric" mode of Pressure Recording Analytical Method. Forty patients were enrolled in this study. Median age, weight, and body surface area at surgery were 3 months (interquartile range, 10 days to 3.5 yr), 5.6 (3.1-15) kg, and 0.31 (0.21-0.56), respectively. During the modified ultrafiltration procedure, a median volume of 17 mL/kg (11-25) was ultrafiltered and a median volume of 11 mL/kg (6-17) was reinfused with a median final modified ultrafiltration balance of -0.15 mL/kg (-4.0 to 0.1). By univariate analyses, there was a 10% increase in postmodified ultrafiltration mean, systolic and diastolic pressures (p = 0.01), stroke volume index (p = 0.02), and cardiac index (p = 0.001) without significant changes in heart rate, central (left and right) venous pressures, stroke volume variation, and inotropic score. By multivariate analysis, when controlling for cardiopulmonary bypass time and age at surgery, cardiac index variation was independently associated with lower preoperative body surface area (beta coefficient -5.5, p = 0.04). According to Pressure Recording Analytical Method assessment, modified ultrafiltration acutely improves myocardial function, as shown by a 10% increase of systemic arterial pressure, stroke volume index, and cardiac index. This effect is more pronounced in smaller sized patients.
Septic shock is an important cause of morbidity and mortality in critically ill children. Early m... more Septic shock is an important cause of morbidity and mortality in critically ill children. Early mortality usually results from resistant hypotension with progressive acidosis refractory to fluid resuscitation and high-dose catecholamine administration. Findings have shown that ...
Bleeding during and after cardiac surgery is a major issue in pediatric patients. A prospective c... more Bleeding during and after cardiac surgery is a major issue in pediatric patients. A prospective cohort study was conducted to evaluate the effect of a commercially available prothrombin complex (Confidex) administered in cardiac surgery after weaning from cardiopulmonary bypass of infants with nonsurgical bleeding. In this study, 14 patients younger than 1 year received a Confidex bolus and were matched with 11 patients of a similar age who did not receive the drug. The preoperative coagulation profile was similar in the two groups. No side effects, including anaphylaxis or thrombotic events, were observed. The numbers of units of packed red blood cells and fresh frozen plasma administered both intra- and postoperatively were similar. The postoperative coagulation examination results and thromboelastographic parameters did not differ significantly between the two groups. However, the Confidex patients bled significantly less than the control subjects during the first 24 postoperative hours. The median volume of drained blood was 0.0 ml/kg h (range 0-1.9 ml/kg h) compared with 1.9 ml/kg h (range 1-3 ml/kg h) (p = 0.009). At least one unit of packed red blood cells in the postoperative phase was required by 2 patients (14 %) in the Confidex group and six patients (54 %) in the control group (odds ratio [OR], 0.13; 95 % confidence interval [CI], 0.02-0.9; p = 0.03). The median duration of mechanical ventilation was 3 days (range 2-4 days) in the Confidex group and 4 days (range 0-8 days) in the control group (p = 0.66). The median stay in the intensive care unit was 6 days (range 5-9 days) in the Confidex group and 7 days (range 4-12 days) in the control group (p = 0.88). The use of Confidex for infants undergoing cardiac surgery was safe and effective. It reduced postoperative bleeding and allowed fewer units of packed red blood cells to be infused in the postoperative phase without major side effects.
It is currently uncertain which hemodynamic monitoring device reliably measures stroke volume and... more It is currently uncertain which hemodynamic monitoring device reliably measures stroke volume and tracks cardiac output changes in pediatric cardiac surgery patients. To evaluate the difference between stroke volume index (SVI) measured by pressure recording analytical method (PRAM) and bioreactance and their ability to track changes after a therapeutic intervention. A single-center prospective observational cohort study in children undergoing cardiac surgery with cardiopulmonary bypass (CPB) was conducted. Twenty children below 20 kg with median (interquartile range) weight of 5.3 kg (4.1-7.8) and age of 6 months (3-20) were enrolled. Data were collected after anesthesia induction, at the end of CPB, before fluid administration and after fluid administration. Overall, median-IQR PRAM SVI values (23 ml·m(-2), 19-27) were significantly higher than bioreactance SVI (15 ml·m(-2), 12-25, P = 0.0001). Correlation (r(2) ) between the two methods was 0.15 (P = 0.0003). The mean difference between the measurements (bias) was 5.7 ml·m(-2) with a standard deviation of 9.6 (95% limits of agreement ranged from -13 to 24 ml·m(-2)). Percentage error was 91.7%. Baseline SVI appeared to be similar, but PRAM SVI was systematically greater than bioreactance thereafter, with the highest gap after the fluid loading phase: 13 (12-18) ml·m(-2) vs. 23 (19-25) ml·m(-2), respectively, P = 0.0013. A multivariable regression model showed that a significant independent inverse correlation with patients' body weight predicted the CI difference between the two methods after fluid challenge (β coefficient -0.12, P = 0.013). Pressure recording analytical method and bioreactance provided similar SVI estimation at stable hemodynamic conditions, while bioreactance SVI values appeared significantly lower than PRAM at the end of CPB and after fluid replacement.
To evaluate the safety and efficacy of levosimendan in neonates with congenital heart disease und... more To evaluate the safety and efficacy of levosimendan in neonates with congenital heart disease undergoing cardiac surgery with cardiopulmonary bypass (CPB). Neonates undergoing risk-adjusted classification for congenital heart surgery (RACHS) 3 and 4 procedures were randomized to receive either a 72 h continuous infusion of 0.1 μg/kg/min levosimendan or standard post-CPB inotrope infusion. Sixty-three patients (32 cases and 31 controls) were recruited. There were no differences between groups regarding demographic and baseline clinical data. No side effects were observed. There were no significant differences in mortality (1 vs. 3 patients, p = 0.35), length of mechanical ventilation (5.9 ± 5 vs. 6.9 ± 8 days, p = 0.54), and pediatric cardiac intensive care unit (PCICU) stay (11 ± 8 vs. 14 ± 14 days, p = 0.26). Low cardiac output syndrome occurred in 37 % of levosimendan patients and in 61 % of controls (p = 0.059, OR 0.38, 95 % CI 0.14-1.0). Postoperative heart rate, with a significant difference at 6 (p = 0.008), 12 (p = 0.037), and 24 h (p = 0.046), and lactate levels, with a significant difference at PCICU admission (p = 0.015) and after 6 h (p = 0.048), were lower in the levosimendan group. Inotropic score was significantly lower in the levosimendan group at PCICU admission, after 6 h and after 12 h, (p < 0.0001). According to multivariate analysis, a lower lactate level 6 h after PCICU admission was independently associated with levosimendan administration after correction for CPB time and the need for deep hypothermic circulatory arrest. Levosimendan infused in neonates undergoing cardiac surgery was well tolerated with a potential benefit of levosimendan on postoperative hemodynamic and metabolic parameters of RACHS 3-4 neonates.
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