Ralph E. Delius

Extracorporeal membrane oxygenation as a bridge to definitive tracheal surgery in children

Extracorporeal membrane oxygenation was used as a bridge for three infants with complicated long segment congenital tracheal stenosis to tracheal homograft transplantation with cadaveric tracheal homograft and for one child, with an extensive traumatic tracheal laceration caused by aspiration of a sharp foreign body, to definitive tracheal repair. In all four cases mechanical ventilation was impossible and death almost certain without extracorporeal membrane oxygenation.

Cumulative Corticosteroid Exposure and Infection Risk After Complex Pediatric Cardiac Surgery

BACKGROUNDnChildren undergoing cardiac surgery may receive corticosteroids preoperatively to temper cardiopulmonary bypass-related inflammation, postoperatively for hemodynamic instability, and periextubation to reduce airway edema. Recent data have associated preoperative corticosteroids with infection. We aimed to determine if there is a relationship between cumulative corticosteroid exposure and infection.nnnMETHODSnA retrospective review of children who underwent cardiac surgery at our institution from January 2009 to July 2010 was performed. To limit study heterogeneity, patients who were 5 years or younger with basic Aristotle score of 7 or higher and intensive care unit stay of 7 days or more were included. Infections during the first 30 postoperative days were recorded, defined as clinically relevant positive blood, urine, respiratory, or wound cultures, or culture-negative sepsis treated with 7 or more days of antimicrobial therapy. Multivariate logistic regression analysis was performed to determine independent risk factors for infection.nnnRESULTSnSeventy-six patients were reviewed. All patients received intraoperative methylprednisolone, 48% received postoperative hydrocortisone, and 86% received periextubation dexamethasone. Twenty-six patients (36%) had 58 infections. On univariate analysis, patients with infection had greater median comprehensive Aristotle score (14.5 [intraquartile range (IQR): 12.5 to 16] versus 11.5 [IQR: 10 to 13.1], p = 0.001), maximum vasoactive inotrope score (29 [IQR: 24 to 40] versus 24 [IQR: 17 to 31], p = 0.031, days endotracheally intubated (12 [IQR: 7 to 30] versus 5 [IQR: 4 to 6.5], p < 0.001), and days of corticosteroid exposure (7 [IQR: 5 to 12] versus 4 [IQR: 2 to 5), p < 0.001). Also, patients with infections more often underwent delayed sternal closure (p = 0.008). On multivariate analysis, days endotracheally intubated (p = 0.023) and days of corticosteroid exposure (p = 0.015) remained significant.nnnCONCLUSIONSnFor children undergoing complex cardiac surgery, greater cumulative duration of corticosteroid exposure is independently associated with postoperative infection.

Arginine vasopressin to manage hypoxemic infants after stage I palliation of single ventricle lesions

Objective: Management of patients with single ventricle physiology following stage I palliation procedures is often challenging, with optimization of the ratio of pulmonary-to-systemic blood flow as an important goal. Persistent hypoxemia may be a manifestation of elevated pulmonary vascular resistance and therefore decreased blood flow to the lungs. In such situations, the use of arginine vasopressin to increase systemic vascular resistance may be an effective strategy to improve pulmonary blood flow and maintain adequate pulmonary-to-systemic blood flow ratio. We describe three infants in whom persistent hypoxemia improved after institution of arginine vasopressin. Design: Retrospective chart review. Setting: Twenty-four bed medical-surgical pediatric intensive care unit at a large tertiary care academic hospital. Patients: Three neonates with single ventricle physiology who received arginine vasopressin in the setting of hypoxemia following stage I palliation. Results: Arginine vasopressin was initiated in all three patients for hypoxemia with a goal to increase systemic vascular resistance and generate a higher driving pressure for pulmonary blood flow. Twelve hours after arginine vasopressin initiation, systemic arterial saturation as determined by pulse oximetry and blood pressure increased, whereas heart rate, inotrope score, and Fio2 decreased in all three patients. Urine output was maintained and arterial lactate decreased during this time. Pulmonary-to-systemic flow ratio increased in one patient in whom it could be determined. Conclusion: In patients with single ventricle physiology and persistent hypoxemia following stage I palliation, administration of arginine vasopressin could improve oxygenation possibly by increasing systemic vascular resistance and therefore the pulmonary blood flow.

Single-stage versus 2-stage repair of coarctation of the aorta with ventricular septal defect

OBJECTIVEnThe results of single-stage and 2-stage repair of coarctation of the aorta with ventricular septal defect have improved, but the optimal treatment strategy remains controversial. This study compares our results with these 2 approaches.nnnMETHODSnWe performed a retrospective analysis of 46 patients, 23 with single-stage repair and 23 with 2-stage repair, who underwent completed surgical treatment of coarctation of the aorta with a ventricular septal defect at the Childrens Hospital of Michigan between March 1994 and June 2006.nnnRESULTSnThe average number of operations in the single-stage group was 1.5 +/- 0.6, and in the 2-stage group it was 2.2 +/- 0.4 (P < or = .0001). Postoperative complications were similar, except for the number of planned reoperations to perform delayed sternal closure in the single-stage operation (n = 7) compared with the 2-stage operation (n = 1, P = .023). The patient age in the single-stage group at the time of discharge (completed repair time) was a median of 39.0 days (range, 19-250 days) compared with a median of 113.0 days (range, 26-1614 days) in the 2-stage group after stage 2 (P < or = .0001). Freedom from cardiac reintervention was 89.8% in the single-stage group versus 84.9% in the 2-stage group (P = .33). The hospital mortality was 4.4% (1 patient) in each group. The actuarial survival rate was 95.7% in the single-stage group versus 90.6% in the 2-stage group (P = .38).nnnCONCLUSIONSnThe advantages of single-stage over 2-stage repair of a ventricular septal defect with coarctation of the aorta include an earlier age at completion of repair, fewer operations, and fewer incisions. Postoperative complications and hospital mortality are similar. The one disadvantage of a single-stage repair was the increased need for delayed sternal closure compared with the 2-stage approach.

Relative deficiency of arginine vasopressin in children after cardiopulmonary bypass

Objective:To describe changes in plasma arginine vasopress in concentration in children following cardiopulmonary bypass and determine whether, in some patients, plasma arginine vasopressin remains relatively low despite hemodynamic instability. Design:Prospective observational study. Setting:Pediatric intensive care unit at a tertiary care university hospital. Patients:One hundred twenty patients ≤18 yrs of age undergoing open heart surgery requiring cardiopulmonary bypass at Childrens Hospital of Michigan between January 2008 and January 2009. Interventions:Blood samples were collected before cardiopulmonary bypass and 4, 24, and 48 hrs after cardiopulmonary bypass for measurement of plasma arginine vasopressin concentration. Measurements and Main Results:Mean plasma arginine vasopressin (pg/mL) for all patients was 21 ± 63 before cardiopulmonary bypass and 80 ± 145, 43 ± 79, and 19 ± 25 at 4, 24, and 48 hrs, respectively, after cardiopulmonary bypass. Patients with plasma arginine vasopressin below the lower quartile (<9.2 pg/mL) at 4 hrs after cardiopulmonary bypass (n = 29), labeled group A, were examined separately and compared with the rest of the study population, labeled group B. Mean plasma arginine vasopressin was 4.9 ± 2.6 in group A at 4 hrs after cardiopulmonary bypass, statistically unchanged from its baseline mean plasma arginine vasopressin of 5.0 ± 10.4 (p = .977). Mean plasma arginine vasopressin in group B was 104 ± 160 at 4 hrs after cardiopulmonary bypass. Mean plasma arginine vasopressin of group A was also significantly lower as compared with group B before and 24 and 48 hrs after cardiopulmonary bypass. Hemodynamics, inotrope score, and serum sodium did not differ between groups at any time point. Plasma arginine vasopressin was measured immediately before exogenous arginine vasopressin administration in 10 patients; only those (n = 3) with hemodynamic instability and relatively low plasma arginine vasopressin concentration (<9.2 pg/mL) had notable hemodynamic improvement. Conclusions:In some children undergoing open heart surgery, plasma arginine vasopressin concentration is relatively low at baseline and remains low after cardiopulmonary bypass regardless of hemodynamic stability and serum osmolality. These children are likely the optimal candidates for exogenous arginine vasopressin should hemodynamic compromise occur.

Vasoactive Inotropic Score (VIS) as Biomarker of Short-Term Outcomes in Adolescents after Cardiothoracic Surgery

Our aim was to evaluate the Vasoactive Inotropic Score (VIS) as a prognostic marker in adolescents following surgery for congenital heart disease. This single-center retrospective chart review included patients 10–18xa0years of age, who underwent cardiac surgery from 2009 to 2014. Hourly VIS was calculated for the initial 48 postoperative hours using standard formulae and incorporating doses of six pressors. The composite adverse outcome was defined as any one of death, resuscitation or mechanical support, arrhythmia, infection requiring antibacterial therapy, acute kidney injury or neurologic injury. Surgeries were risk-stratified by the type of surgical repair using the validated STAT score. Statistical analysis (SPSS 19.0) included Mann–Whitney U test, Chi-square test, ROC curves, and binary regression analysis. Our cohort (nxa0=xa0149) had a mean (SD) age of 13.9 (2.4) years and included 97 (65.1xa0%) males. Maximal VIS at 24 and 48xa0h following surgery was significantly higher in subjects (nxa0=xa027) who suffered an adverse outcome. Subjects with adverse outcome had longer bypass and cross-clamp times, durations of stay in the hospital, and a higher rate of acute kidney injury, compared to those (nxa0=xa0122) without postoperative adverse outcomes. The area under the ROC for maximum VIS at 24–48xa0h after surgery was 0.76, with sensitivity, specificity, and positive and negative predictive values with 95xa0% CI of 67 (48–82)xa0%, 74 (70–77)xa0%, and 36 (26–44)xa0% and 91 (86–95)xa0%, respectively, at a cutoff >4.75. On binary logistic regression, maximum VIS on second postoperative day remained significantly associated with adverse outcome (OR 1.35; 95xa0% CI> 1.12–1.64, pxa0=xa00.002). Maximal VIS at 24 and 48xa0h correlated significantly with length of stay and time to extubation. Maximal VIS on the second postoperative day predicts adverse outcome in adolescents following cardiac surgery. This simple yet robust prognostic indicator may aid in risk stratification and targeted interventions in this population.

Passive peritoneal drainage improves fluid balance after surgery for congenital heart disease

OBJECTIVEnIn some centers, passive peritoneal drainage (PD) is implemented following surgery for congenital heart disease. The utility of this practice has yet to be studied. We hypothesized that passive PD can promote negative fluid balance without compromising intravascular volume.nnnMETHODSnA retrospective review of infants who underwent repair of complete atrioventricular septal defect (AVSD) between 6/2006 and 8/2010 was completed. Data are represented as mean ± standard deviation.nnnRESULTSnThirty-six infants underwent AVSD repair, 18 of whom had PD catheters placed without complication. Infants with passive PD had longer duration of cardiopulmonary bypass (211 ± 59 vs 137 ± 41 min, P < 0.001) and aortic cross-clamp (148 ± 29 vs 102 ± 21 min, P < 0.001); had higher Aristotle complexity score (12.6 ± 3 vs 10.7 ± 2, P = 0.03) and ventilatory support immediately after surgery (ventilation index score 19.5 ± 6.5 vs 14.3 ± 2.5, P = 0.004); and received greater fluid administration (225 ± 6 3 vs 168 ± 45 ml kg(-1), P = 0.002) in the first 48 postoperative hours. Despite these differences, infants with passive PD achieved negative fluid balance more rapidly (12 ± 10 vs 27.3 ± 13 h, P < 0.0001) and to a greater extent (-73 + 55 vs +2.6 + 39 mL kg(-1) at 48 h, P = 0.002). Moreover, postoperative hemodynamics, urine output, creatinine clearance, blood urea nitrogen, peak lactate, and duration of mechanical ventilation were similar between groups.nnnCONCLUSIONSnPassive PD is safe and promotes negative fluid balance after repair of complete AVSD without adversely affecting intravascular volume.

Effect of inhaled corticosteroid on pulmonary injury and inflammatory mediator production after cardiopulmonary bypass in children.

Objective: To determine whether inhaled steroid administration after cardiopulmonary bypass will attenuate pulmonary inflammation and improve lung compliance and oxygenation. Design: Randomized, prospective, double-blind, placebo-controlled clinical trial. Setting: Children’s Hospital of Michigan, intensive care unit. Patients: Thirty-two children <2 yrs of age with congenital heart disease requiring cardiopulmonary bypass. Interventions: Participants were randomly assigned to one of two groups. Group 1 (n = 16) received an inhaled steroid, Budesonide (0.25 mg/2 mL), and group 2 (n = 16) received an inhaled placebo (2 mL of inhaled 0.9% saline). The nebulizations were given at the end of cardiopulmonary bypass, 6 hrs after cardiopulmonary bypass, and 12 hrs after cardiopulmonary bypass. Two hours after each nebulization, bronchoalveolar lavage for interleukin-6 and interleukin-8 was collected. Measurements and Main Results: The concentrations of interleukin-6 and interleukin-8 in the bronchoalveolar lavage increased in both groups after cardiopulmonary bypass. Interleukin-6 peaked 2 hrs after cardiopulmonary bypass and was decreasing by 14 hrs after cardiopulmonary bypass. However, administration of corticosteroid did not affect the production of interleukin-6 when compared with the placebo group (378 ± 728 vs. 287 ± 583 pg/mL pre-cardiopulmonary bypass, 1662 ± 1410 vs. 1584 ± 1645 pg/mL at the end of cardiopulmonary bypass, 2601 ± 3132 vs. 3677 ± 4935 pg/mL 2 hrs after cardiopulmonary bypass, and 1792 ± 3100 vs. 1283 ± 1344 pg/mL 14 hrs after cardiopulmonary bypass; p > .05). Likewise, interleukin-8 in the lavage fluid was similar in both the placebo and steroid groups at all time points (570 ± 764 vs. 990 ± 1147 pg/mL pre-cardiopulmonary bypass, 1647 ± 1232 vs. 1394 ± 1079 pg/mL at the end of cardiopulmonary bypass, 1581 ± 802 vs. 1523 ± 852 pg/mL 2 hrs after cardiopulmonary bypass, and 1652 ± 1069 pg/mL vs. 1808 ± 281 pg/mL 14 hrs after cardiopulmonary bypass; p > .05). Lung compliance and oxygenation were similar in both groups. Conclusions: Cardiopulmonary bypass is associated with a pulmonary inflammatory response. Inhaled corticosteroid did not affect the pulmonary inflammatory response as measured by interleukin-6 and interleukin-8 concentrations in the lung lavage after cardiopulmonary bypass. Pulmonary mechanics and oxygenation were not improved by the use of inhaled corticosteroid.

Low donor-to-recipient weight ratio does not negatively impact survival of pediatric heart transplant patients.

Tang L, Du W, Delius RE, L’Ecuyer TJ, Zilberman MV. Low donor‐to‐recipient weight ratio does not negatively impact survival of pediatric heart transplant patients.u2028Pediatr Transplantation 2010: 14:741–745.

Risk Factors for Extubation Failure Following Neonatal Cardiac Surgery.

Objective: Extubation failure after neonatal cardiac surgery has been associated with considerable postoperative morbidity, although data identifying risk factors for its occurrence are sparse. We aimed to determine risk factors for extubation failure in our neonatal cardiac surgical population. Design: Retrospective chart review. Setting: Urban tertiary care free-standing children’s hospital. Patients: Neonates (0–30 d) who underwent cardiac surgery at our institution between January 2009 and December 2012 was performed. Interventions: Extubation failure was defined as reintubation within 72 hours after extubation from mechanical ventilation. Multivariate logistic regression analysis was performed to determine independent risk factors for extubation failure. Measurements and Main Results: We included 120 neonates, of whom 21 (17.5%) experienced extubation failure. On univariate analysis, patients who failed extubation were more likely to have genetic abnormalities (24% vs 6%; p = 0.023), hypoplastic left heart (43% vs 17%; p = 0.009), delayed sternal closure (38% vs 12%; p = 0.004), postoperative infection prior to extubation (38% vs 11%; p = 0.002), and longer duration of mechanical ventilation (median, 142 vs 58 hr; p = 0.009]. On multivariate analysis, genetic abnormalities, hypoplastic left heart, and postoperative infection remained independently associated with extubation failure. Furthermore, patients with infection who failed extubation tended to receive fewer days of antibiotics prior to their first extubation attempt when compared with patients with infection who did not fail extubation (4.9 ± 2.6 vs 7.3 ± 3; p = 0.073). Conclusions: Neonates with underlying genetic abnormalities, hypoplastic left heart, or postoperative infection were at increased risk for extubation failure. A more conservative approach in these patients, including longer pre-extubation duration of antibiotic therapy for postoperative infections, may be warranted.