Eduardo M. da Cruz

Enteral Feeding in Prostaglandin-Dependent Neonates: Is It a Safe Practice?

In many centers presurgical term neonates with prostaglandin-dependent cardiac lesions experience nutritional deficiency because of postponed enteral feeds. We recently adopted early enteral feeding in these infants. This retrospective study demonstrates feeding tolerance in 33 of 34 neonates fed enterally while receiving prostaglandin, suggesting the safety of this practice.

Oral feeding outcomes in neonates with congenital cardiac disease undergoing cardiac surgery.

BACKGROUND Achievement of adequate oral nutrition is a challenging task after early neonatal cardiac surgery. This study aims to describe predictors of oral feeding outcomes for neonates after early surgical interventions. MATERIALS AND METHODS A retrospective review of neonates admitted with congenital cardiac disease over a period of 1 year. We analysed predictors of the need for a feeding tube at discharge and the amount taken at each feeding. Multilevel modelling was used to look at individual change over time predicting oral amount at each feeding. RESULTS We identified 56 neonates. Diagnoses were heterogeneous; 23% of the infants had associated genetic syndromes and 45% required pre-operative mechanical ventilation. The median time from birth to surgery was 8.4 days, with 29 infants fed orally before surgery. The mean time from surgery to first oral feeding attempt was 12 hours. Time from surgery to oral feeding, the amount taken with first feeding, and cross-clamp times were significant predictors of oral feeding success, whereas the presence of a comorbidity--genetic abnormality--and longer ventilator dependency predicted failure. Almost half of the neonates required a feeding tube upon discharge, and no infant discharged was solely breastfed. Discharge with a feeding tube was associated with greater weight gain at that time. CONCLUSIONS Neonates with congenital cardiac disease face significant barriers to successfully achieving oral feeding on hospital discharge. Enteral feeding guidelines focus on physiological stabilisation and do not always address the developmental milestones necessary to support oral feeding. Future prospective studies are necessary to identify multimodal strategies to optimise early feeding.

Enteral feeding in neonates with prostaglandin-dependent congenital cardiac disease: international survey on current trends and variations in practice

BACKGROUND The benefits of early enteral feeding in neonates are well known and yet the optimal pre-operative nutrition of prostaglandin-dependent infants with congenital cardiac disease remains ill-defined. This survey delineates international nutritional practices and trends with this population. MATERIALS AND METHODS Paediatric practitioners responded to an Internet-based survey that explored assessment of feeding practices, criteria for feeding readiness, medication dosing, concurrent feeding with umbilical catheters, and the observed incidence of feeding intolerance. Documented nutritional strategies were not correlated with patient outcomes. RESULTS A total of 200 caregivers responded to the survey. Fewer United States caregivers (56%) reported routine pre-operative enteral feeding in prostaglandin-dependent infants when compared with caregivers outside the United States of America (93%). Of those respondents willing to feed, approximately two-thirds did not base their decision on the ductal flow direction. Numerous and heterogeneous parameters were reported to assess feeding readiness. Many caregivers report scepticism with regard to enteral feeding safety in neonates with an umbilical artery catheter, and to a lesser extent in the presence of an umbilical venous catheter. In summary, there is a prevailing lack of consensus regarding pre-operative enteral nutrition to prostaglandin-dependent neonates. CONCLUSIONS This survey demonstrates noticeable variations in pre-operative nutritional practices between providers from around the world. Arguments that support or refute this practice have little support in the medical literature. Future studies should aim to demonstrate the safety of such practice and compare the outcomes of prostaglandin-dependent neonates who were pre-operatively enterally fed with those who were not.

Bronchoscopic Diagnosis of Asymptomatic Unilateral Pulmonary Vein Atresia in an Infant

An eight-month-old boy with findings of persistent left pulmonary basal infiltrate was diagnosed with congenital unilateral pulmonary vein atresia by bronchoscopy. Cardiac catheterization documented slow left pulmonary venous return to atretic pulmonary veins. Conservative treatment was chosen because the child was asymptomatic and corrective surgery or percutaneous intervention was not technically possible. After a 3-year follow-up, the child still has no documented pulmonary hypertension. Early diagnosis of unilateral pulmonary vein atresia is important to anticipate potential threatening complications like pulmonary hypertension and hemoptysis. Surgical treatment of this entity might be drastic and complex and should be weighed against a conservative alternative and careful follow-up.

Propofol as a bridge to extubation for high-risk children with congenital cardiac disease.

BACKGROUND Children with congenital cardiac defects may have associated chromosomal anomalies, airway compromise, and/or pulmonary hypertension, which can pose challenges to adequate sedation, weaning from mechanical ventilation, and successful extubation. Propofol, with its unique properties, may be used as a bridge to extubation in certain cardiac populations. MATERIALS AND METHODS We retrospectively reviewed 0-17-year-old patients admitted to the Cardiac Intensive Care Unit between January, 2007 and September, 2008, who required mechanical ventilation and received a continuous infusion of propofol as a bridge to extubation. Medical charts were reviewed for demographics, associated comorbidities, as well as additional sedation medications and haemodynamic trends including vital signs and vasopressor support during the peri-infusion period. Successful extubation was defined as no re-intubation required for respiratory failure within 48 hours. Outcomes measured were successful extubation, evidence for propofol infusion syndrome, haemodynamic stability, and fluid and inotropic requirements. RESULTS We included 11 patients for a total of 12 episodes. Propofol dose ranged from 0.4 to 5.6 milligram per kilogram per hour with an average infusion duration of 7 hours. All patients were successfully extubated, and none demonstrated worsening metabolic acidosis suggestive of the propofol infusion syndrome. All patients remained haemodynamically stable during the infusion with average heart rates and blood pressures remaining within age-appropriate ranges. One patient received additional fluid but no increase in vasopressors was needed. CONCLUSIONS This study suggests that propofol infusions may allow for successful extubation in a certain population of children with congenital cardiac disease. Further studies are required to confirm whether propofol is an efficient and safe alternative in this setting.

Predicting recovery: Successful explant of a ventricular assist device in a child with dilated cardiomyopathy

A previously healthy, 13-year-old girl presented with new-onset dilated cardiomyopathy, and is placed on a left ventricular assist device (VAD). Herein we describe a unique VAD weaning protocol used to determine the timing and feasibility of a VAD explant.

A Multicenter Survey of Heparin Prophylaxis Practice in Pediatric Critical Care

Heparin prophylaxis (HP) is commonly used for prevention of central venous catheter (CVC)-related complications among pediatric intensivists, yet efficacy of this therapy is unknown. We conducted a survey of pediatric intensivists and their experiences with HP. A total of 96 responses were received. Almost half of the respondents regularly used HP in patients with CVCs, yet most were unsure of its benefit. The majority of respondents claimed to experience no adverse effects; the complications that were reported to occur were related to bleeding or suspected heparin-induced thrombocytopenia (HIT). Overall, participants felt CVC-associated HP was safe in pediatric critical illness, while acknowledging the paucity of compelling data.

Tachyarrhythmia Following Norwood Operation A Single-Center Experience

Background: The purpose of this study was to characterize tachyarrhythmias in children following the Norwood procedure. Methods: This is a single-center retrospective study including all children who underwent stage I Norwood procedure (n = 98; January 2003-September 2011). The primary outcome measure is the development of tachyarrhythmia during hospitalization after the Norwood procedure. Secondary aims include quantification of mortality in patients with tachyarrhythmias and evaluation of potential risk factors for the development of tachyarrhythmia. Results: Tachyarrhythmia occurred in 33 (34%) of 98 patients. The median time to onset of tachyarrhythmia was ten days (0-47 days). Tachyarrhythmia conferred no increase in overall mortality (P = .45), including operative mortality (P = .37) or interstage mortality (P = 1.00). There was no significant difference in the incidence of arrhythmia based on demographic, anatomic, or surgical variables, including shunt type (P = .23) except that patients with tachyarrhythmias were slightly larger (median weight 3.2 kg) at the time of stage I than those without tachyarrhythmia (median weight 2.93 kg; P = .02]. The odds of arrhythmia in males were 8.7 times higher than that in females (95% confidence interval 2.9-31.3; P < .0001). Conclusions: Postoperative tachyarrhythmia is common, occurring in 34% of patients after the Norwood operation. Onset of tachyarrhythmia occurred later after the Norwood operation than reported previously, and male gender is a risk factor. Further studies to elucidate the etiology and the timing of tachyarrhythmias after the Norwood procedure are necessary.

Prenatal diagnosis and successful outcome in neonate of aorto-left ventricle tunnel.

Aorto‐left ventricular tunnel (ALVT) is an abnormal congenital communication between the ascending aorta and the left ventricle. Prenatal diagnosis is rare and can be misinterpreted as aortic insufficiency on fetal echocardiogram. We present a case of ALVT diagnosed in a fetus who underwent successful early neonatal surgical repair.

Perioperative Management of Shock in Two Fontan Patients With Plastic Bronchitis

Plastic bronchitis is potentially a life-threatening complication of long-standing surgically palliated single ventricle congenital heart disease. Patients can present with hypoxia requiring urgent bronchoscopy for removal of bronchial casts. Perioperative care for these patients is challenging and anesthesia is associated with significant cardiac risk. As more surgically corrected single ventricle patients survive to adulthood, these patients are expected to present more frequently. This report details the perioperative management of 2 Fontan patients with hypoxia and significant plastic bronchitis disease burden.