Linhua Tan

Perioperative Risk Factors for Prolonged Mechanical Ventilation Following Cardiac Surgery in Neonates and Young Infants

BACKGROUND Prolonged mechanical ventilation (PMV) after cardiac surgery in children is associated with a high postoperative morbidity and mortality, as well as increased ICU and hospital resource utilization. Little has been done to identify the predictors of PMV in neonates and young infants. This study was performed to evaluate the perioperative risk factors for PMV in neonates and young infants undergoing cardiac surgery. METHODS Clinical records of 172 consecutive children aged < or = 3 months were reviewed. PMV was defined as mechanical ventilation (MV) > or = 72 h following operation. After univariate analysis, a stepwise logistic regression analysis was used to evaluate the independent risk factors for PMV following cardiac surgery. The predictive ability of risk factors for PMV was assessed using an area under the receiver operating characteristic (ROC) curve. RESULTS Sixty-one patients required PMV after cardiac surgery. The median duration of MV was 150 h in PMV patients, while it was 28 h in non-PMV patients. The independent risk factors for PMV were risk adjustment for surgery for congenital heart disease (RACHS)-1 (p = 0.041), nosocomial pneumonia (p = 0.001), low cardiac output syndrome (LCOS) [p = 0.001], postoperative cumulative positive fluid balance (p = 0.032), and extubation failure (EF) [p = 0.027]. The value for the ROC curve was 0.940. CONCLUSIONS The present results strongly suggest that RACHS-1, nosocomial pneumonia, LCOS, fluid retention postoperatively, and EF are risk factors for PMV in neonates and young infants undergoing reparative surgery for congenital heart disease.

Plasma sRAGE enables prediction of acute lung injury after cardiac surgery in children

IntroductionAcute lung injury (ALI) after cardiac surgery is associated with a high postoperative morbidity and mortality, but few predictors are known for the occurrence of the complication. This study evaluated whether elevated plasma levels of soluble receptor for advanced glycation end products (sRAGE) and S100A12 reflected impaired lung function in infants and young children after cardiac surgery necessitating cardiopulmonary bypass (CPB).MethodsConsecutive children younger than 3 years after cardiac surgery were prospectively enrolled and assigned to ALI and non-ALI groups, according to the American-European Consensus Criteria. Plasma concentrations of sRAGE and S100A12 were measured at baseline, before, and immediately after CPB, as well as 1 hour, 12 hours, and 24 hours after operation.ResultsFifty-eight patients were enrolled and 16 (27.6%) developed postoperative ALI. Plasma sRAGE and S100A12 levels increased immediately after CPB and remained significantly higher in the ALI group even 24 hour after operation (P < 0.01). In addition, a one-way MANOVA revealed that the overall sRAGE and S100A12 levels were higher in the ALI group than in the non-ALI group immediately after CPB (P < 0.001). The multivariate logistic regression analysis showed that the plasma sRAGE level immediately after CPB was an independent predictor for postoperative ALI (OR, 1.088; 95% CI, 1.011 to 1.171; P = 0.025). Increased sRAGE and S100A12 levels immediately after CPB were significantly correlated with a lower PaO2/FiO2 ratio (P < 0.01) and higher radiographic lung-injury score (P < 0.01), as well as longer mechanical ventilation time (sRAGEN: r = 0.405; P = 0.002; S100A12N: r = 0.322; P = 0.014), longer surgical intensive care unit stay (sRAGEN: r = 0.421; P = 0.001; S100A12N: r = 0.365; P = 0.005) and hospital stay (sRAGEN: r = 0.329; P = 0.012; S100A12N: r = 0.471; P = 0.001).ConclusionsElevated sRAGE and S100A12 levels correlate with impaired lung function, and sRAGE is a useful early biomarker of ALI in infants and young children undergoing cardiac surgery.

Neonate With Vein of Galen Malformation and Heart Failure: Serial Changes in Plasma B-Type Natriuretic Peptide Following Endovascular Embolization

We report a neonate with vein of Galen malformation (VGM) who developed congestive heart failure (CHF) early after birth. Serial changes in plasma B-type natriuretic peptide (BNP) following an endovascular embolization procedure for VGM were mirrored in his clinical CHF status. The plasma BNP level markedly increased to 1800 pg/ml (normal, <100 pg/ml) in accordance with the severity of CHF. It rapidly decreased to 356 pg/ml during the first week after endovascular embolization for VGM. In the following 3 weeks there was an unexpected upward trend in plasma BNP despite echocardiography revealing normal biventricular function. After additional evaluation and treatment for CHF, BNP decreased again and the patient’s clinical status concurrently improved. The patient was discharged with a normal BNP level. Monitoring serial plasma BNP provides valuable information regarding the need for additional evaluation or treatment of newborns with CHF and may be used to document improvement.

High shear stress-induced pulmonary hypertension alleviated by endothelial progenitor cells independent of autophagy

BackgroundPulmonary hypertension (PH) is a progressive disease characterized by lung endothelial cell dysfunction and vascular remodeling. Endothelial progenitor cells (EPCs) have been proved to be a potential therapeutic strategy to treat PH. Autophagy has been found to be protective to hypoxia-induced PH. In this study, we applied high shear stress (HSS)-induced PH, and examined whether EPCs confer resistance against HSS-induced PH through autophagy.MethodsPulmonary microvascular endothelial cells (PMVECs) were cultured under HSS with pro-inflammatory factors in an artificial capillary system to mimic the PH condition. Levels of p62, a selective autophagy substrate, were quantified by western blotting. Cell viability was determined by trypan blue exclusion test.ResultsThe p62 level in PMVECs was increased at 4 hours after HSS, peaked at 12 hours and declined at 24 hours. The cell viability gradually decreased. Compared with PMVECs cultured by empty medium, in cells cultured by EPC-conditioned medium (EPC-CM), the cell viability was significantly higher; however, p62 levels were also significantly higher, suggesting inhibition of autophagy by EPC-CM. Adding choloquine to suppress autophagy decreased the cell viability of PMVECs under PH.ConclusionsEPC-CM could suppress the autophagic activity of PMVECs in HSS-induced PH. However, suppression of autophagy leads to cell death. EPCs could fight against PH through cellular or molecular pathways independent of autophagy. But it is not proved if induction of autophagy could be a potential strategy to treat HSS-induced PH as hypoxia-induced PH.

Performance of Pediatric Risk of Mortality, Pediatric Index of Mortality and PIM2 in term Chinese neonates

Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality (PIM) and PIM2 could be applicable to the subset of term neonates has not been well investigated. The purpose of this study is to access and compare the performance of these scoring systems in predicting mortality probability in term Chinese neonates with critical illness. PRISM, PIM and PIM2 scores were calculated prospectively during a 1-year period on 243 neonates admitted to the neonatal intensive care unit (NICU) in the Childrens Hospital of Zhejiang University in China. Of these, 36 neonates (14.81%) died in the NICU, while the mortality rates estimated by PRISM, PIM and PIM2 were 16.19, 14.58 and 11.12%, respectively. The area under the receiver-operating characteristic (ROC) curve [95% confidence intervals (CIs)] were 0.834 (0.767-0.902), 0.851 (0.786-0.916) and 0.854 (0.790-0.918) for PRISM, PIM and PIM2, respectively. The Hosmer-Lemeshow test gave a chi-square of 1.35 (p = 0.930) for PRISM, 1.03 (p = 0.960) for PIM and 4.58 (p = 0.469) for PIM2. The standardized mortality rates (SMRs) (95% CI) using PRISM, PIM and PIM2 were 0.92 (0.79-1.08), 1.02 (0.88-1.20) and 1.33 (1.13-1.62), respectively. Although PRISM, PIM and PIM2 have displayed good discrimination and calibration in the present setting, PIM is considered as the most accurate and appropriate tool for predicting mortality in the studied NICU.

Extracorporeal membrane oxygenation for the treatment of children with severe hemodynamic alteration in perioperative cardiovascular surgery.

BackgroundThis article summarizes the use of extracorporeal membrane oxygenation (ECMO) for the treatment of children with severe hemodynamic alteration in perioperative cardiovascular surgery.MethodsFour children with congenital heart disease (CHD) (3 boys and 1 girl, aged 6 days to 4 years and weighing 2.8–15 kg) associated with severe heart failure and/or hypoxemia were treated with ECMO cardiopulmonary support in perioperative cardiovascular surgery between July 2007 and July 2008. We retrospectively analyzed the medical records of the 4 children.ResultsOf the 4 children, 2 survived and 2 died. The survivors were treated with venoarterial (VA) ECMO due to severe low output syndrome after arterial switch operation. They were weaned successfully from 22-hour and 87-hour ECMO support, and discharged 20 days and 58 days after ECMO explantation, respectively. The other boy treated with venovenous ECMO died of severe hypoxemia and metabolic acidosis. The other girl with VSD, treated with VA ECMO because of failure to wean from cardiopulmonary bypass, died from irreversible heart failure 11 hours after ECMO explantation. The main complications in this series included pulmonary hemorrhage, blood tamponade, surgical site bleeding, hemolysis and hyperbilirubinemia.ConclusionsECMO is an effective therapy for patients with severe heart failure in the perioperative cardiovascular surgery. The keys to successful ECMO are selection of indications, time to set up ECMO, and good management of complications during ECMO.

Tigecycline salvage therapy for critically ill children with multidrug-resistant/extensively drug-resistant infections after surgery

OBJECTIVE The aim of this study was to evaluate the efficacy and safety of salvage therapy of tigecycline in critically ill children with infections caused by multidrug-resistant (MDR)/extensively drug-resistant (XDR) bacteria after surgery. METHODS A retrospective chart review was performed of critically ill children after surgery who had received tigecycline for ≥3days between June 2012 and May 2016 in the surgical intensive care unit of a tertiary level childrens hospital. RESULTS Of 6442 consecutive children admitted after surgery, a total of 22 were enrolled. They had a median age of 7.5 months (interquartile range (IQR), 6 months to 4 years) and a median weight of 7.3kg (IQR, 5.1-12.5kg). Patients received tigecycline for a median 17days (IQR, 12-20 days). The median intensive care unit stay was 56days (IQR, 38-61 days) and median hospital stay was 78days (IQR, 61-94 days). Tigecycline was prescribed as culture-directed therapy in 91% of patients and as empirical therapy in 9%. Clinical success was reported in 86% of the patients. The all-cause mortality in this cohort was 18%. No serious adverse effects of tigecycline were detected in these patients. CONCLUSIONS Tigecycline salvage therapy was successful in 86% of critically ill pediatric patients with MDR/XDR infections after surgery, with no severe adverse effects.