Andrée De Ville

Perioperative volume replacement in children undergoing cardiac surgery: albumin versus hydroxyethyl starch 130/0.4

Objective:To compare 4% albumin with 6% hydroxyethyl starch (HES) 130/0.4 in terms of perioperative blood loss and intraoperative fluid requirements in children undergoing cardiac surgery. Design:Prospective randomized study. Setting:Single University Hospital. Patients:Pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Interventions:One hundred nineteen children were randomized to receive up to 50 mL·kg−1 of either 4% albumin (Alb: n = 59) or 6% HES 130/0.4 (HES: n = 60) for intraoperative fluid volume replacement including the cardiopulmonary bypass priming fluid. Ringers lactate was used for further intraoperative volume needs. Monitoring, anesthetic, and surgical techniques were standardized. Packed red blood cells were administered according to a strict transfusion protocol. Intra- and postoperative blood loss were measured and also calculated from childrens estimated blood volume, pre- and postoperative hematocrit, and volume of transfused packed red blood cells. Measurements and Main Results:Volume of colloid used intraoperatively was similar in both groups (median [interquartiles]) (Alb: 50 [45–50] mL·kg−1; HES: 50 [37–50] mL·kg−1). Measured and calculated blood loss were not different between groups, but a higher number of children in the albumin group required allogeneic blood transfusion (78% vs. 57%; difference between proportions: 0.213; 95% confidence interval: 0.05–0.38; p = 0.0188). Intraoperative fluid balance was lower in the HES group (Alb 23 [11–39] mL·kg−1; HES: 12 [−5–30] mL·kg−1; p = 0.005). Postoperative outcome was not different between groups. Conclusions:In children undergoing cardiac surgery, 6% HES 130/0.4 may represent an interesting alternative to 4% albumin for intraoperative fluid volume replacement because of its lower cost.

Plasma fibrinogen concentration is correlated with postoperative blood loss in children undergoing cardiac surgery. A retrospective review.

BACKGROUND Fibrinogen supplementation is increasingly recommended with the use of rotational thromboelastometry (ROTEM). However, data regarding the paediatric population are sparse. OBJECTIVE We aimed to assess the relationship between plasma fibrinogen concentration and postoperative blood loss in children undergoing cardiac surgery. DESIGN Retrospective analysis. SETTING Data prospectively recorded in our departmental database between September 2010 and January 2012. PATIENTS Data from 156 children scheduled for congenital heart surgery with ROTEM performed at the end of cardiopulmonary bypass (CPB) were analysed. INTERVENTION None. MAIN OUTCOME MEASURES Abnormal bleeding was defined as blood loss that exceeded 10% of total blood volume within the first 6 postoperative hours. Logistic regression analyses were used to determine variables associated with bleeding. Correlation analyses and receiver operating characteristic (ROC) curves were designed to evaluate the relationship between blood loss and plasma fibrinogen concentration or ROTEM variables, if relevant. RESULTS Thirty-six children were considered as ‘bleeders’ and 120 as ‘nonbleeders’. Univariate and multivariate logistic regression analysis revealed time for wound closure, clot formation time, maximal clot firmness (MCF) and plasma fibrinogen concentration as variables independently associated with postoperative bleeding. MCF was best correlated with plasma fibrinogen concentration. ROC curves for blood loss versus fibrinogen concentration and MCF showed that a plasma fibrinogen concentration of 1.5 g l−1 and a MCF value 3 mm or less could be used to predict blood loss. CONCLUSION Post-CPB plasma fibrinogen concentration significantly influences blood loss in children undergoing cardiac surgery. A fibrinogen concentration of at least 1.5 g l−1 or a MCF of at least 3 mm should accurately predict excessive blood loss in cardiac surgery children. Further prospective trials are needed to assess the effect of fibrinogen supplementation on postoperative blood loss in this population.

Six Percent Hydroxyethyl Starch 130/0.4 (Voluven®) versus 5% Human Serum Albumin for Volume Replacement Therapy during Elective Open-heart Surgery in Pediatric Patients

Background:Although 5% albumin (human serum albumin [HSA]) is widely used in cardiac surgery children, synthetic colloids may provide a valuable alternative. This study compared 6% hydroxyethyl starch (HES) 130/0.4 with HSA for volume replacement in this population. Methods:The study was a two-center, randomized, controlled, parallel-group, double-blind trial performed in children aged 2–12 yr undergoing elective surgery for congenital heart disease under extracorporeal circulation. The primary objective was to demonstrate equivalence between HES and HSA with regard to the total volume of colloid infusion for intraoperative volume replacement including priming of the extracorporeal circuitery. Results:In the per-protocol population, mean volume of colloid required until end of surgery was (mean ± SD) 36.6 ± 11.8 ml/kg body weight in the HES group (N = 29) and 37.0 ± 11.9 ml/kg body weight in the HSA group (N = 26; ratio of means HES/HSA = 0.98 [95% CI, 0.84–1.16]). Intraoperative fluid balance was less positive in the HES group (P = 0.047). No difference was found regarding hemodynamics, the use of vasoactive and inotropic drugs. Blood loss, erythrocytes transfusion, and renal function were not different between groups. The incidence of adverse events up to postoperative day 28 did not differ between the groups. Conclusions:In pediatric cardiac surgery, HES showed equivalence to HSA with regard to volume replacement therapy in children aged from 2 to 12 yr. Although there was no suggestion of an imbalance of safety measures between HES and HSA, the study was not powered to provide any firm conclusions about safety of tetrastarch in this population.

Heart block following propofol in a child

We present the case of a nine‐year‐old boy afflicted with Ondines curse, who developed complete atrioventricular heart block after a single bolus of propofol for induction of anaesthesia for strabismus surgery. Ondines curse, the other name for congenital central hypoventilation syndrome, is characterized by a generalized disorder of autonomic function. Propofol has no effect on the normal atrioventricular conduction system in humans but it reduces sympathetic activity and can highly potentiate other vagal stimulation factors. Heart block has been documented after propofol bolus use in adults but, to our knowledge, not in children. It would appear that propofol is not a good choice for anaesthesia in congenital central hypoventilation syndrome.

Remifentanil versus morphine-midazolam premedication on the quality of endotracheal intubation in neonates: A noninferiority randomized trial

OBJECTIVE To compare remifentanil and morphine-midazolam for use in nonurgent endotracheal intubation in neonates. STUDY DESIGN In this prospective noninferiority randomized trial, newborns of gestational age ≥28 weeks admitted in the neonatal intensive care unit requiring an elective or semielective endotracheal intubation were divided into 2 groups. One group (n = 36) received remifentanil (1 μg/kg), and the other group (n = 35) received morphine (100 μg/kg) and midazolam (50 μg/kg) at a predefined time before intubation (different in each group), to optimize the peak effect of each drug. Both groups also received atropine (20 μg/kg). The primary outcome was to compare the conditions of intubation, and the secondary outcome was to compare the duration of successful intubation, physiological variables, and pain scores between groups for first and second intubation attempts. Adverse events and neurologic test data were reported. RESULTS Intubation with remifentanil was not inferior to that with morphine-midazolam. At the first attempted intubation, intubation conditions were poor in 25% of the remifentanil group and in 28.6% of the morphine-midazolam group (P = .471). For the second attempt, conditions were poor in 28.6% of the remifentanil group, compared with 10% of the morphine-midazolam group (P = .360). The median time to successful intubation was 33 seconds (IQR, 24-45 seconds) for the remifentanil group versus 36 seconds (IQR, 25-59 seconds) for the morphine-medazolam group (P = .359) at the first attempt and 45 seconds (IQR, 35-64 seconds) versus 56 seconds (IQR, 44-68 seconds), respectively, for the second attempt (P = .302). No significant between-group difference was reported for hypotension, bradycardia, or adverse events. CONCLUSION In our cohort, remifentanil was at least as effective as the morphine-midazolam regimen for endotracheal intubation. Thus, premedication using this very-short-acting opioid can be considered in urgent intubations and is advantageous in rapid extubation.

Neurophysiologic detection of a unilateral motor deficit occurring during the noncritical phase of scoliosis surgery.

Study Design A four-path neurophysiologic monitoring system was designed for spinal cord monitoring during spinal surgery. It was used mainly during scoliosis surgery. Objective To evaluate the efficacy of this technique. Methods Sensory and motor pathways were continuously monitored bilaterally from skin incision to awakening, with independent evaluation of the right and left pathways for each modality. Results This monitoring technique detected a trensient unilateral motor deficit that occurred during the dissection phase of spinal surgery for scoliosis before any instrumentation or mobilization of the spine.

Placement of an automatic implantable cardioverter-defibrillator in a 6-month-old infant: Anesthetic management

V ENTRICULAR FIBRILLATION is an uncommon event in pediatric patients. It may be observed after electrocution, during and after cardiac surgery, or in the presence of certain myocardial diseases.~ Automatic implanted cardioverterdefibrillators (AICD) are an easy-to-perform and efficient therapy in adult and pediatric patients for the prevention of sudden cardiac death resulting from malignant ventricular arrhythmia. 2,3 AICD therapy remains rare in infants younger than 1 year of age, and anesthesia for such a procedure has not yet been described in the pediatric age group. The authors report a case of AICD insertion under caudal epidural and general anesthesia in a 6-month-old infant suffering from ventricular tachyarrhythmia as a result of a large right ventricnlar congenital tumor.

Impact of On-Bypass Red Blood Cell Transfusion on Severe Postoperative Morbidity or Mortality in Children.

BACKGROUND:Children undergoing cardiac surgery are frequently exposed to red blood cell (RBC) transfusions mainly in the case of hemorrhage or low oxygen transport. However, in this population, RBCs are sometimes added to the cardiopulmonary bypass (CPB) priming solution to maintain a predefined hematocrit on bypass. In this study, we investigated the impact of RBCs added to the CPB on severe postoperative morbidity or mortality. METHODS:This retrospective cohort study was conducted between 2006 and 2012 in a tertiary care level, children’s hospital. Children receiving red cells only to prime the CPB (CPB transfusion) were compared with those receiving no RBCs during their entire hospital stay. The primary outcome was severe postoperative morbidity or mortality. Studied secondary outcomes were neurologic deficit, infection, length of mechanical ventilation, pediatric intensive care unit and hospital length of stay, and mortality. Both groups were compared with propensity score analysis where patients were matched via a genetic matching algorithm. In all analyses, applying a Bonferroni correction, a P value <.05/8 = .00625, was considered statistically significant. RESULTS:Among the 854 patients retained for this study, 439 (51.4%) received no RBC transfusion during their entire hospital stay and 415 (49.6%) received a CPB transfusion. Thirty-five (8.0%) patients in the no-transfusion group and 110 (26.5%) patients in the CPB transfusion group developed severe postoperative morbidity or died. This difference was statistically significant using univariate analysis (P < .001). Propensity score analysis showed that 79 (19.55%) patients developed severe postoperative morbidity or died in the no-transfusion group compared with 103 (25.50%) patients in the CPB transfusion group (P = .043). The relative risk and its Bonferroni-corrected confidence interval was 0.77 (0.53–1.10). All secondary outcomes were not significantly different between both groups, except the number of patients who developed infections (P < .001). CONCLUSIONS:In the condition of our study, adding RBCs to the CPB priming to maintain a predefined hematocrit does not seem to impact markedly severe postoperative morbidity or mortality in children undergoing cardiac surgery. Only the risk of infection was increased in the CPB transfusion group. Further studies are warranted to better understand the complex interaction among severity of illness, anemia, RBCs transfusion, and outcome in children undergoing cardiac surgery.

Heparin Reversal After Cardiopulmonary Bypass: Are Point-of-Care Coagulation Tests Interchangeable?

OBJECTIVE Protamine is used to neutralize heparin after patient separation from cardiopulmonary bypass (CPB). Different bedside tests are used to monitor the adequacy of heparin neutralization. For this study, the interchangeability of the activated coagulation time (ACT) and thromboelastometry (ROTEM; Tem Innovations GmbH, Basel, Switzerland) clotting time (CT) ratios in children undergoing cardiac surgery was assessed. DESIGN Single-center, retrospective, cohort study between September 2010 and January 2012. SETTING University childrens hospital. PARTICIPANTS The study comprised children 0 to 16 years old undergoing elective cardiac surgery with CPB. Exclusion criteria were preoperative coagulopathy, Jehovahs witnesses, and children in a moribund condition (American Society of Anesthesiologists score 5). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After heparin neutralization with protamine, the ratio between ACT, with and without heparinase, and the CT measured with INTEM/HEPTEM (intrinsic test activated with ellagic acid was performed without heparinase [INTEM] and with heparinase [HEPTEM]) using tests of ROTEM were calculated. Agreement was evaluated using Cohens kappa statistics, Passing-Bablok regression, and Bland-Altman analysis. Among the 173 patients included for analysis, agreement between both tests showed a Cohens kappa statistic of 0.06 (95% CI: -0.02 to 0.14; p = 0.22). Bland-Altman analysis showed a bias of 0.01, with a standard deviation of 0.13, and limits of agreement between -0.24 and 0.26. Passing-Bablok regression showed a systematic difference of 0.40 (95% CI: 0.16-0.59) and a proportional difference of 0.61 (95% CI: 0.42-0.86). The residual standard deviation was 0.11 (95% CI: -0.22 to 0.22), and the test for linearity showed p = 0.10. CONCLUSION ACT, with or without heparinase, and the INTEM/HEPTEM CT ratios are not interchangeable to evaluate heparin reversal after pediatric patient separation from CPB. Therefore, the results of these tests should be corroborated with the absence/presence of bleeding and integrated into center-specific treatment algorithms.