Paula Rautiainen

Junctional ectopic tachycardia after surgery for congenital heart disease: incidence, risk factors and outcome

OBJECTIVES Junctional ectopic tachycardia (JET) is a serious, haemodynamically compromising tachyarrhythmia associated with paediatric cardiac surgery, with a reported mortality up to 14%. The incidence, risk factors and outcome of this tachyarrhythmia were evaluated in this population-based, case-control patient cohort. METHODS A total of 1001 children, who underwent open-heart surgery during a 5-year period, were retrospectively analysed. The patients with haemodynamically significant tachycardia were identified, and their postoperative electrocardiograms were analysed. Three controls matched with the same type of surgery were selected for each patient with JET. RESULTS JET was diagnosed in 51 patients (5.0%). These patients had longer cardiopulmonary bypass time (138 vs 119 min, p=0.002), higher body temperature (38.0 vs 37.4 °C, p=0.013) and higher level of postoperative troponin-T (3.7 vs 2.1 μg l(-1), p<0.001) compared with controls. They also needed longer ventilatory support (3 vs 2 days, p=0.004) and intensive care stay (7 vs 5 days, p<0.001) as well as use of noradrenaline (23/51 vs 35/130, p=0.019). Ventricular septal defect (VSD) closure was part of the surgery in 33/51 (64.7%) of these patients. The mortality was 8% in the JET group and 5% in the controls (p=0.066). In the logistic regression model, JET was not an independent risk factor for death (p=0.557). CONCLUSIONS The incidence of JET was 5.0% in this large paediatric open-heart surgery patient group. Compared with controls, these patients had longer cardiopulmonary bypass time and higher level of troponin-T, possibly reflecting the extent of surgical trauma. However, the tachycardia was not an independent risk factor for death.

Amrinone Versus Dopamine-Nitroglycerin After Reconstructive Surgery for Complete Atrioventricular Septal Defect

OBJECTIVES To compare the effectiveness and safety of amrinone and a combination of dopamine and nitroglycerin in infants after reconstructive surgery for congenital heart disease. DESIGN A prospective, randomized, double-blind study. SETTING Pediatric intensive care unit in a university hospital. PARTICIPANTS Thirty-two infants with complete atrioventricular septal defect. INTERVENTIONS Amrinone loading dose, 2 mg/kg, followed by a maintenance infusion, 7.5 micrograms/kg/min, was given to 17 infants before separation from cardiopulmonary bypass. The remaining 15 patients received a combination of dopamine, 5 micrograms/kg/min, and nitroglycerin, 1 microgram/kg/min. MEASUREMENTS AND MAIN RESULTS The circulatory state of the patients was evaluated from 4 to 18 hours after cardiopulmonary bypass. The systemic blood flow index, calculated using the Fick principle, was higher in the amrinone group (2.5 +/- 0.7 L/min/m2) compared with the dopamine-nitroglycerin group (2.0 +/- 0.6 L/min/m2, mean +/- SD). The pulmonary blood flow index in the amrinone group was higher (2.9 +/- 0.6 L/min/m2) than in the dopamine-nitroglycerin group (2.2 +/- 0.6 L/min/m2); no significant difference was noted in the mean pulmonary artery pressure. The oxygen extraction ratio was higher in the dopamine-nitroglycerin group (0.41 +/- 0.07) compared with the amrinone group (0.34 +/- 0.08). Despite lower platelet counts in the amrinone group, no hemorrhagic complications were seen in any patient. CONCLUSIONS With this dosage regimen, amrinone provides a higher cardiac output, more favorable oxygen dynamics, and lower pulmonary vascular resistance than dopamine and nitroglycerin.

Alfentanil and fentanyl sedation in infants and small children during cardiac catheterization

Thirty patients aged 1–23 mth received either alfentanil or fentanyl for the induction and maintenance of IV sedation during cardiac catheterization following oral flunitrazepam premedication (0.1 mg · kg−1). Patients breathed spontaneously 30 per cent oxygen in air. Both alfentanil and fentanyl abolished all reaction to pain and discomfort with minimal haemodynamic and respiratory changes. Induction doses of alfentanil and fentanyl were 20 ± 6 and 2.5 ± 1.1 (mean ± SD) μg · kg−1, respectively, and maintenance requirements 30 ± 12 and 1.5 ± 0.6 μg · kg−1 · h−1, respectively. These requirements were comparable among younger and older as well as cyanotic and acyanotic patients. The TV sedation described adds an effective method to the armamentarium of an anaesthetist working in the cardiac laboratory.RésuméTrente patients âgés de 1 à 23 mois ont reçu soit de l’alfentanil soit du fentanyl pour l’induction et le maintien de la sédation intraveineuse durant le cathétérisme cardiaque après une prémédication au flunitrazépam (0,1 mg · kg−1). Les patients respiraient spontanément 30 pour cent d’oxygène dans l’air. L’alfentanil el le fentanyl ont aboli la rèaction et la douleur avec des changements minimes tant hémodynamiques que respiratoires. Les doses d induction d’alfentanil et de fentanyl étaient respectivement 20 ± 6 et 2,5 ± 1,1 (moyenne ± SD) μg · kg−1, respectivement, et les doses de maintien étaient 30 ± 12 et 1,5 ± 0.6 μg · kg−1 · hres−1, respectivement. Ces doses étaient comparables chez les jeunes et les moins jeunes ainsi que chez les patients présentant une cyanose ou ceux qui étaient acyanotiques. La sédation intraveineuse décrite ajoute une méthode efficace à l’armatorium de l’anesthésiste ceuvrant dans le laboratoire de cardiologie.

Alfentanil infusion for sedation in infants and small children during cardiac catheterization

We have analyzed several sedation techniques for paediatric cardiac catheterization which offer stable conditions for a few hours investigation, and maintain spontaneous breathing. In the present study, after premedication with oral flunitrazepam 0.1 mg · kg−1, 14 children aged 1–17 mo were sedated with an individually titrated alfentanil infusion. Every patient was sedated to a level which produced no reaction to pain or any discomfort. The induction dose and the maintenance requirement of alfentanil were 24 ± 8 μg · kg− 1 and 32 ± 8 μg · kg− 1 · hr− 1 (mean ± SD), respectively. These doses were less in cyanotic than in acyanotic patients: 21 ± 6 vs 28 ± 8 μg · kg− 1 and 29 ± 10 vs 34 ± 3 μg · kg− 1 · hr− 1, respectively (P < 0.05). The mean plasma concentration of alfentanil during maintenance of sedation was 79 ± 23 ng · ml− 1. Ventilation of two children was assisted for a short time after an incremental bolus of alfentanil. It is concluded that an alfentanil infusion technique with close monitoring of breathing is a practical sedation method for paediatric cardiac catheterization.RésuméNous avons évalué plusieurs techniques de sédation appropriées au cathétérisme cardiaque chez les enfants. La technique idéale doit produire une condition stable pendant quelques heures chez un enfant qui respire spontanément. Au cours de cette étude, après une prémédication au flunitrazépam oral à raison de 0,1 mg · kg− 1, on titrait de l’alfentanil par voie intraveineuse chez 14 enfants âgés de 1 à 17 mois de telle sorte qu’ils ne réagissent ni à la douleur ni à l’inconfort. Les doses moyennes d’induction et de maintien nécessaires furent respectivement de 24 ± 8 μg · kg− 1 et de 32 ± 8μg · kg− 1 · h− 1 (moy ± écart-type). Toutefois, elles étaient moins grandes chez les enfants cyanotiques que chez les autres, soit: 21 ± 6vs28 ± 8 μg · kg− 1 et 29 ± 10 vs 34 ± 3 μg · kg− 1 · h− 1, respectivement. La concentration plasmatique moyenne d’alfentanil pendant la phase de maintien était de 79 ± 23 ng · ml− 1. Après un bolus supplémentaire d’alfentanil, on dut assister la ventilation de deux enfants pendant quelques instants. Donc, l’infusion d’alfentanil couplé à un monitorage serré de la respiration constitue une technique de sédation pratique pour le cathétérisme cardiaque chez les enfants.

Amrinone versus dopamine and nitroglycerin in neonates after arterial switch operation for transposition of the great arteries.

OBJECTIVE To compare the efficacy and safety of amrinone and a combination of dopamine and nitroglycerin in neonates after reconstructive surgery for transposition of the great arteries. DESIGN A prospective, randomized, double-blind study. SETTING Pediatric intensive care unit in a university hospital. PARTICIPANTS Thirty-five neonates with transposition of the great arteries. INTERVENTIONS A loading dose of amrinone, 2 mg/kg, followed by a maintenance infusion of 7.5 microg/kg/min, were administered to 16 neonates before separation from cardiopulmonary bypass. The remaining 19 patients were administered a combination of dopamine, 5 microg/kg/min, and nitroglycerin, 1 microg/kg/min. An open-label epinephrine infusion was administered in both groups as required. MEASUREMENTS AND MAIN RESULTS The circulatory state of the patients was evaluated from 4 to 18 hours after cardiopulmonary bypass. The systemic blood flow index, calculated using the Fick principle, was higher in the amrinone group (1.7+/-0.5 L/min/m2 [mean +/- SD]) compared with the dopamine-nitroglycerin group (1.4+/-0.4 L/min/m2; p < 0.04). The systemic vascular resistance in the amrinone group was lower (26+/-8 Wood units x m2) than in the dopamine-nitroglycerin group (35+/-12 Wood units x m2; p < 0.02). The oxygen extraction ratio was higher in the dopamine-nitroglycerin group (0.34+/-0.08) compared with the amrinone group (0.28+/-0.06; p < 0.02). Lower platelet counts were observed in the amrinone group, but no difference in hemorrhagic complications was seen between the groups. CONCLUSION With the dosage regimen used, supplemented with epinephrine, amrinone provides a higher cardiac output and more favorable oxygen dynamics than a combination of dopamine and nitroglycerin.

The Effect of Methylprednisolone on Plasma Concentrations of Neutrophil Gelatinase-Associated Lipocalin in Pediatric Heart Surgery.

Objectives: Plasma neutrophil gelatinase–associated lipocalin is a kidney injury marker used in pediatric heart surgery. Neutrophil gelatinase–associated lipocalin is also a constituent of specific granules of neutrophils. Corticosteroids are widely used in pediatric heart surgery. Methylprednisolone inhibits degranulation of neutrophil-specific granules. Use of corticosteroids has not been taken into account in studies of neutrophil gelatinase–associated lipocalin in pediatric heart surgery. We studied the influence of systemically administered methylprednisolone on plasma neutrophil gelatinase–associated lipocalin concentrations in pediatric heart surgery. Design: Two separate double-blinded randomized trials. Setting: PICU at a university-affiliated hospital. Patients: Forty neonates undergoing open-heart surgery and 45 children undergoing ventricular and atrioventricular septal defect correction. Interventions: First trial (neonate trial), 40 neonates undergoing open-heart surgery received either 30 mg/kg IV methylprednisolone (n = 20) or placebo (n = 20). Second trial (ventricular septal defect trial), 45 children undergoing ventricular or atrioventricular septal defect correction received one of the following: 30 mg/kg of methylprednisolone IV after anesthesia induction (n = 15), 30 mg/kg methylprednisolone in the cardiopulmonary bypass prime solution (n = 15), or placebo (n = 15). Measurements and Main Results: Plasma neutrophil gelatinase–associated lipocalin and creatinine were measured in both series. Lactoferrin levels were measured as a marker of neutrophil-specific granules in the ventricular septal defect trial only. No differences in creatinine levels occurred between the groups of either trial. Preoperative, neutrophil gelatinase–associated lipocalin did not differ between the study groups of either trial. Preoperatively administered methylprednisolone in the neonate trial reduced neutrophil gelatinase–associated lipocalin by 41% at 6 hours postoperatively (p = 0.002). Preoperatively administered methylprednisolone in the ventricular septal defect trial reduced neutrophil gelatinase–associated lipocalin by 47% (p = 0.010) and lactoferrin by 52% (p = 0.013) 6 hours postoperatively. Lactoferrin levels in the ventricular septal defect trial correlated with neutrophil gelatinase–associated lipocalin (R = 0.492; p = 0.001) preoperatively and after weaning from cardiopulmonary bypass (R = 0.471; p = 0.001). Conclusions: Preoperatively administered methylprednisolone profoundly decreases plasma neutrophil gelatinase–associated lipocalin levels. Neutrophil gelatinase–associated lipocalin seems to originate to a significant extent from activated neutrophils. Preoperative methylprednisolone is a confounding factor when interpreting plasma neutrophil gelatinase–associated lipocalin levels as a kidney injury marker in pediatric heart surgery.

The effect of continuous wound infusion of ropivacaine on postoperative pain after median sternotomy and mediastinal drain in children

Postoperative pain after median sternotomy is usually treated with i.v. opioids. We hypothesized that continuous wound infusion of ropivacaine decreases postoperative morphine consumption and improves analgesia in children who undergo cardiac surgery.

Thrombin regulation in neonates undergoing cardiopulmonary bypass

Satu Långström1, Paula Rautiainen2, Leena Mildh2, Kaija Peltola2, Ulla Wartiovaara-Kautto3, Markku Heikinheimo1,4, Jari Petäjä1,5 1Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland; 2Department of Anesthesia and Intensive Care, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland; 3Helsinki University Central Hospital Laboratory Services (HUSLAB), Department of Clinical Chemistry, Laboratory of Hematology, University of Helsinki, Finland; 4Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA; 5Department of Pediatrics, Jorvi Hospital, University of Helsinki, Espoo, Finland

Intravenous sedation for children with Down's syndrome undergoing cardiac catheterization

Downs syndrome is commonly associated with cardiac malformations and sleep related upper airway obstruction. The dose response for ketamine in the presence of an infusion of fentanyl was determined in 28 consecutive children (3–51 months) with Downs syndrome and congenital heart disease during haemodynamic catheterization. The children were premedicated with flunitrazepam orally and glycopyrrolate i.v. Ventilation was continuously monitored with a capnograph. Fentanyl 1 μg·kg−1 and 1 μg·kg−1·h−1 was administered in fixed doses for induction and maintenance of sedation, respectively. The mean induction and maintenance requirements of ketamine were 1.5 ± 0.5 mg·kg−1 and 1.8 ± 0.8 mg·kg−1·h−1, respectively. In infants younger than 6 months, more ketamine was needed for both induction and maintenance than in older children (P < 0.005). Normoventilation without any airway manipulation could be maintained in 15 patients (54%). Respiratory difficulties were frequent: hypoventilation required temporary mask ventilation, insertion of a nasopharyngeal tube or tracheal intubation in two, seven and four children, respectively. Oral flunitrazepam premedication and intravenous sedation with low‐dose fentanyl and ketamine combined with close monitoring of ventilation can be used for cardiac catheterization in children with Downs syndrome. However, the described combination of sedative drugs does not prevent the occurrence of sleep related upper airway obstruction.

Alfentanil sedation for cardiac catheterization of children with Fontan shunts

After Fontan operation, prolonged invasive cardiac assessment is often needed. This study is a clinical evaluation of the effectiveness of flunitrazepam premedication, EMLA® cream, and alfentanil continuous infusion for management of children undergoing such catheterization. Fourteen consecutive subjects aged 5– 20 yr with Fontan shunts (right atrium to pulmonary artery) undergoing elective haemodynamic and electrophysiological catheterization were sedated with an individually titrated alfentanil infusion. After oral premedication with flunitrazepam 2 mg, the mean induction dose and mean maintenance requirement of alfentanil were 4.4 ± 2.7 μg · kg− 1 and 10.3 ± 8.6 μg · kg− 1 · hr− 1, respectively. Mean oxygen consumption during haemodynamic catheterization was 4.1 ± 0.4 ml · kg− 1 · min− 1 with an average individual variation of 10%. For every patient, tranquil and stable conditions during catheterization could be produced. It is concluded that alfentanil infusion is a method of sedation of children and adolescents with Fontan shunts during haemodynamic and electrophysiologic catheterization. However, continuous monitoring of ventilation and an understanding of the slow circulation time after Fontan operation are essential with such sedation in these patients.RésuméAprès une opération de Fontan, l’installation d’un monitorage cardiaque invasif nécessite souvent beaucoup de temps. Cette étude est une évaluation clinique de l’efficacité d’une prémedication au flunitrazépam, de la crème EMLA® et d’une infusion continue d’alfentanil pour la prise en charge de patients soumis à un tel cathétérisme. Quatorze sujets âgés de 5 à 20 ans porteurs d’un shunt de Fontan (oreillette droite vers artère pulmonaire) programmés pour un cathétérisme hémodynamique et électrophysiologique ont reçu une sédation avec une infusion d’alfentanil titrée individuellement. Après une prémédication orale au flunitrazépam 2 mg, la dose moyenne dinduction puis d’entretien d’alfentanil a été de 4, 4 ± 2,7 μg · kg− 1 et de 10,3 ± 8,6 μg · kg · hr− 1 respectivement. La consommation moyenne d’oxygène pendant le cathétérisme hémodynamique a été de 4,1 ± 0,4 ml · kg · min− 1 avec une variation individuelle moyenne de 10%. En conclusion, on a procuré pour chaque patient des conditions tranquilles et stables pendant le cathétérisme. Néanmoins, un monitorage continu de la ventilation ainsi que la notion de l’existence d’un temps de circulation prolongé après une intervention de Fontan sont essentielles pour une telle sédation chez ces patients.