Safety and utility of modified ultrafiltration in pediatric cardiac surgery

Perfusion ◽  
2021 ◽  
pp. 026765912110436
Author(s):  
David A Palanzo ◽  
Robert K Wise ◽  
Karl R Woitas ◽  
Akif Ündar ◽  
Joseph B Clark ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Heart Surgery ◽  
Congenital Heart Surgery ◽  
Hemodynamic Parameters ◽  
Circulating Blood Volume ◽  
Venous Cannula ◽  
Transfusion Requirements ◽  
Total Body ◽  
Aortic Cannula

Introduction: Modified ultrafiltration (MUF) is employed at the termination of cardiopulmonary bypass (CPB) in pediatric and neonatal patients undergoing congenital heart surgery to reduce the accumulation of total body water thus increasing the concentration of red blood cells and the other formed elements in the circulation. Modified ultrafiltration has been reported to remove circulating pro-inflammatory mediators that result in systemic inflammatory response syndrome (SIRS) postoperatively. Methods: Four hundred patients undergoing cardiac surgery requiring cardiopulmonary bypass and weighing less than or equal to 12 kg were retrospectively evaluated for the effectiveness of MUF. After the termination of CPB, blood was withdrawn through the aortic cannula and passed through a hemoconcentrator attached to the blood cardioplegia set and returned to the patient through the venous cannula. The entire CPB circuit volume in addition to the patient’s circulating blood volume were concentrated until the hematocrit value displayed on the CDI cuvette within the MUF circuit reached 45% or there was no more volume to safely remove. At the same time a full unit of FFP can be infused as water is being removed, thus maintaining euvolemia. Results: MUF was performed in all 400 patients with no MUF-related complications. Following the conclusion of MUF, anecdotal observations included improved surgical hemostasis, improved hemodynamic parameters, decreased transfusion requirements, and decreased ventilator times. Conclusions: Complete MUF enables the clinician to safely raise the post-CPB hematocrit to at least 40% while potentially removing mediators that could result in SIRS. In addition a full unit of FFP can be administered while maintaining euvolemia.

scholarly journals Safety of Normothermic Cardiopulmonary Bypass in Pediatric Cardiac Surgery: A System Review and Meta-Analysis

2021 ◽  
Vol 9 ◽  
Author(s):  
Tao Xiong ◽  
Lei Pu ◽  
Yuan-Feng Ma ◽  
Yun-Long Zhu ◽  
Xu Cui ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Congenital Heart ◽  
Heart Surgery ◽  
Meta Analysis ◽  
Congenital Heart Surgery ◽  
Mean Difference ◽  
Pediatric Cardiac Surgery ◽  
Controlled Trials ◽  
Cochrane Central Register

Objectives: Hypothermic cardiopulmonary bypass (HCPB) has been used successfully in cardiac surgery for more than half a century, although adverse effects have been reported with its use. Many studies on temperature management during CPB published to date have shown that normothermic CPB (NCPB) provides more benefits to children undergoing cardiac surgery. The present meta-analysis investigated the effect of NCPB on clinical outcomes based on results of randomized controlled trials and observational studies on pediatric cardiac surgery.Methods: Databases such as PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Clinical Trials.gov were searched from inception to May 2021 to identify relevant studies published in English.Results: The present meta-analysis included 13 studies characterizing a total of 837 pediatric patients. The random effects model exhibited that the NCPB group had reduced revision for postoperative bleeding [odds ratio (OR): 0.11; 95% confidence interval (CI): 0.01–0.89; I2 = 0%, P = 0.04], serum lactate 2–4 h after CPB (mean difference: −0.60; 95% CI: −1.09 to −0.11; I2 = 82%, P = 0.02), serum creatinemia 24 h after CPB (mean difference: −2.73; 95% CI: −5.06 to −0.39; I2 = 83%, P = 0.02), serum creatinemia 48 h after CPB (mean difference: −2.08; 95% CI: −2.78 to −1.39; I2 = 0%, P < 0.05), CPB time (mean difference: −19.10, 95% CI: −32.03 to −6.18; I2 = 96%, P = 0.04), and major adverse events (OR: 0.37; 95% CI: 0.15–0.93; Z = 2.12, P = 0.03) after simple congenital surgery compared with the HCPB group.Conclusion: NCPB is as safe as HCPB in pediatric congenital heart surgery. Moreover, NCPB provides more advantages than HCPB in simple congenital heart surgery.

scholarly journals Analysis of Dynamic Changes in Cognitive Workload During Cardiac Surgery Perfusionists′ Interactions With the Cardiopulmonary Bypass Pump

2020 ◽  
pp. 001872082097629
Author(s):  
Lauren R. Kennedy-Metz ◽  
Roger D. Dias ◽  
Rithy Srey ◽  
Geoffrey C. Rance ◽  
Heather M. Conboy ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Heart Surgery ◽  
Time Windows ◽  
Open Heart Surgery ◽  
Real Life ◽  
Skin Incision ◽  
Cognitive Workload ◽  
Dynamic Changes ◽  
Pump Operation

Objective This novel preliminary study sought to capture dynamic changes in heart rate variability (HRV) as a proxy for cognitive workload among perfusionists while operating the cardiopulmonary bypass (CPB) pump during real-life cardiac surgery. Background Estimations of operators’ cognitive workload states in naturalistic settings have been derived using noninvasive psychophysiological measures. Effective CPB pump operation by perfusionists is critical in maintaining the patient’s homeostasis during open-heart surgery. Investigation into dynamic cognitive workload fluctuations, and their relationship with performance, is lacking in the literature. Method HRV and self-reported cognitive workload were collected from three Board-certified cardiac perfusionists ( N = 23 cases). Five HRV components were analyzed in consecutive nonoverlapping 1-min windows from skin incision through sternal closure. Cases were annotated according to predetermined phases: prebypass, three phases during bypass, and postbypass. Values from all 1min time windows within each phase were averaged. Results Cognitive workload was at its highest during the time between initiating bypass and clamping the aorta (preclamp phase during bypass), and decreased over the course of the bypass period. Conclusion We identified dynamic, temporal fluctuations in HRV among perfusionists during cardiac surgery corresponding to subjective reports of cognitive workload. Not only does cognitive workload differ for perfusionists during bypass compared with pre- and postbypass phases, but differences in HRV were also detected within the three bypass phases. Application These preliminary findings suggest the preclamp phase of CPB pump interaction corresponds to higher cognitive workload, which may point to an area warranting further exploration using passive measurement.

Post-operative kinetics of C-reactive protein to distinguish between bacterial infection and systemic inflammation in infants after cardiopulmonary bypass surgery: the early and the late period

2021 ◽  
pp. 1-8
Author(s):  
Hanna Renk ◽  
David Grosse ◽  
Sarah Schober ◽  
Christian Schlensak ◽  
Michael Hofbeck ◽  
...  
Keyword(s):  
Cardiopulmonary Bypass ◽  
Bacterial Infection ◽  
Congenital Heart ◽  
Bypass Surgery ◽  
Heart Surgery ◽  
Congenital Heart Surgery ◽  
C Reactive Protein ◽  
Reactive Protein ◽  
Post Operative Period ◽  
Kinetics Of

Abstract Objectives: Differentiation between post-operative inflammation and bacterial infection remains an important issue in infants following congenital heart surgery. We primarily assessed kinetics and predictive value of C-reactive protein for bacterial infection in the early (days 0–4) and late (days 5–28) period after cardiopulmonary bypass surgery. Secondary objectives were frequency, type, and timing of post-operative infection related to the risk adjustment for congenital heart surgery score. Methods: This 3-year single-centre retrospective cohort study in a paediatric cardiac ICU analysed 191 infants accounting for 235 episodes of CPBP surgery. Primary outcome was kinetics of CRP in the first 28 days after CPBP surgery in infected and non-infected patients. Results: We observed 22 infectious episodes in the early and 34 in the late post-operative period. CRP kinetics in the early post-operative period did not accurately differentiate between infected and non-infected patients. In the late post-operative period, infected infants displayed significantly higher CRP values with a median of 7.91 (1.64–22.02) and 6.92 mg/dl (1.92–19.65) on days 2 and 3 compared to 4.02 (1.99–15.9) and 3.72 mg/dl (1.08–9.72) in the non-infection group. Combining CRP on days 2 and 3 after suspicion of infection revealed a cut-off of 9.47 mg/L with an acceptable predictive accuracy of 76%. Conclusions: In neonates and infants, CRP kinetics is not useful to predict infection in the first 72 hours after CPBP surgery due to the inflammatory response. However, in the late post-operative period, CRP is a valuable adjunctive diagnostic test in conjunction with clinical presentation and microbiological diagnostics.

Anemia after Pediatric Congenital Heart Surgery

2021 ◽  
Author(s):  
Kim Anh La ◽  
Camille Jutras ◽  
George Gerardis ◽  
Rachel Richard ◽  
Geneviève Du Pont-Thibodeau
Keyword(s):  
Cardiac Surgery ◽  
Congenital Heart ◽  
Heart Surgery ◽  
Pediatric Intensive Care ◽  
Coarctation Of The Aorta ◽  
Congenital Heart Surgery ◽  
Hypoplastic Left Heart ◽  
Age At Surgery ◽  
Left Heart Syndrome ◽  
Average Hemoglobin

AbstractThe postoperative course of infants following congenital heart surgery is associated with significant blood loss and anemia. Optimal transfusion thresholds for cardiac surgery patients while in pediatric intensive care unit (PICU) remain a subject of debate. The goal of this study is to describe the epidemiology of anemia and the transfusion practices during the PICU stay of infants undergoing congenital heart surgery. A retrospective cohort study was performed in a PICU of a tertiary university-affiliated center. Infants undergoing surgery for congenital heart disease (CDH) before 6 weeks of age between February 2013 and June 2019 and who were subsequently admitted to the PICU were included. We identified 119 eligible patients. Mean age at surgery was 11 ± 7 days. Most common cardiac diagnoses were d-Transposition of the Great Arteries (55%), coarctation of the aorta (12.6%), and tetralogy of Fallot (11.8%). Mean hemoglobin level was 14.3 g/dL prior to surgery versus 12.1 g/dL at the PICU admission. Hemoglobin prior to surgery was systematically higher than hemoglobin at the PICU entry, except in infants with Hypoplastic Left Heart Syndrome. The average hemoglobin at PICU discharge was 11.7 ± 1.9 g/dL. Thirty-three (27.7%) patients were anemic at PICU discharge. Fifty-eight percent of patients received at least one red blood cell (RBC) transfusion during PICU stay. This study is the first to describe the epidemiology of anemia at PICU discharge in infants following cardiac surgery. Blood management of this distinctive and vulnerable population requires further investigation as anemia is a known risk factor for adverse neurodevelopment delays in otherwise healthy young children.

scholarly journals Pre-operative and peri operative predictors of acute renal failure after cardiac surgery

2019 ◽  
Vol 6 (3) ◽  
pp. 756
Author(s):  
Praveen Dhaulta ◽  
Vikas Panwar
Keyword(s):  
Renal Failure ◽  
Acute Renal Failure ◽  
Cardiac Surgery ◽  
Cardiopulmonary Bypass ◽  
Ejection Fraction ◽  
Heart Surgery ◽  
Open Heart Surgery ◽  
Clinical Variable ◽  
Open Heart ◽  
Multiple Variables

Background: Acute kidney injury (AKI) is one of the most serious complications during the postoperative period of cardiac surgery. Multiple variables predict the ARF after cardiac surgery. Objective of this study was to evaluate the significance of pre and peri-operative variables which may help in predicting the chances of developing ARF after cardiac surgery.Methods: This study was an observational, prospective study conducted among patients who were scheduled to undergo open heart surgery under cardiopulmonary bypass.Results: In total, 50 patients who underwent open-heart surgery, ARF was seen in 5 patients, with the incidence rate of 10%. Acute renal failure was present in one patient with ejection fraction <35, 2 patients had ejection fraction between 35 to 50 and 2 patients with ejection fraction >50. It was seen in 4 patients with 1-2 hrs of cardiopulmonary bypass and in 1 patient with >2 hrs of cardiopulmonary bypass. ARF was also seen in 4 patients with hematocrit between 22-26% and in 1 patient with >26%.Conclusions: The study provided a clinical variable score that can predict ARF after open-heart surgery. The score enhances the accuracy of prediction by accounting for the effect of all major risk factors of ARF.

scholarly journals Treatment of systemic inflammatory response syndrome following on-pump pediatric congenital heart surgery

2021 ◽  
Vol 10 (2) ◽  
pp. 113-124
Author(s):  
D. V. Borisenko ◽  
A. A. Ivkin ◽  
D. L. Shukevich
Keyword(s):  
Cardiopulmonary Bypass ◽  
Systemic Inflammatory Response Syndrome ◽  
Inflammatory Response ◽  
Congenital Heart ◽  
Heart Surgery ◽  
Heart Defects ◽  
Surgical Techniques ◽  
Congenital Heart Surgery ◽  
Systemic Inflammatory Response ◽  
Preventive Strategies

Highlights. The article discusses the pathophysiological aspects of cardiopulmonary bypass and the mechanisms underlying the development of the systemic inflammatory response in children following congenital heart surgery. We summarize and report the most relevant preventive strategies aimed at reducing the systemic inflammatory response, including both, CPB-related methods and pharmacological ones.The growing number of children with congenital heart defects requires the development of more advanced technologies for their surgical treatment. However, cardiopulmonary bypass is required in almost all surgical techniques. Despite the tremendous progress and recent advances in cardiopulmonary bypass techniques, the systemic inflammatory response syndrome associated with these surgeries remains unresolved. The review summarizes the causes and mechanisms underlying its development. The most commonly used preventive strategies are reported, including standard and modified ultrafiltration, leukocyte filters, and pharmacological agents (systemic glucocorticoids, aprotinin, and antioxidants).The role of cardioplegia and hypothermia in the reduction of systemic inflammation is defined. Cardiac surgery centers around the world use a variety of techniques and pharmacological approaches, drawing on the results of randomized clinical studies. However, there are no clear and definite clinical guidelines aimed at reducing the systemic inflammatory response during cardiopulmonary bypass in children. It remains a significant problem for pediatric intensive care by aggravating their postoperative status, prolonging the length of the in-hospital stay, and reducing the survival rates.

Analysis of regional congenital cardiac surgical outcomes in Florida using The Society of Thoracic Surgeons Congenital Heart Surgery Database

2009 ◽  
Vol 19 (4) ◽  
pp. 360-369 ◽  
Author(s):  
Jeffrey P. Jacobs ◽  
James A. Quintessenza ◽  
Redmond P. Burke ◽  
Mark S. Bleiweis ◽  
Barry J. Byrne ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Quality Improvement ◽  
Congenital Heart ◽  
Heart Surgery ◽  
Regional Analysis ◽  
The United States ◽  
Congenital Heart Surgery ◽  
Medical Services ◽  
Congenital Cardiac Surgery ◽  
Children's Medical Services

AbstractBackgroundFlorida is the fourth largest state in the United States of America. In 2004, 218,045 live babies were born in Florida, accounting for approximately 1744 new cases of congenital heart disease. We review the initial experience of The Society of Thoracic Surgeons Congenital Heart Surgery Database with a regional outcomes report, namely the Society of Thoracic Surgeons Florida Regional Report.MethodsEight centres in Florida provide services for congenital cardiac surgery. The Children’s Medical Services of Florida provide a framework for quality improvement collaboration between centres. All congenital cardiac surgical centres in Florida have voluntarily agreed to submit data to the Society of Thoracic Surgeons Database. The Society of Thoracic Surgeons and Duke Clinical Research Institute prepared a Florida Regional Report to allow detailed regional analysis of outcomes for congenital cardiac surgery.ResultsThe report of 2007 from the Society of Thoracic Surgeons Congenital Heart Surgery Database includes details of 61,014 operations performed during the 4 year data harvest window, which extended from 2003 through 2006. Of these operations, 6,385 (10.5%) were performed in Florida. Discharge mortality in the data from Florida overall, and from each Florida site, with 95% confidence intervals, is not different from cumulative data from the entire Society of Thoracic Surgeons Database, both for all patients and for patients stratified by complexity.ConclusionsA regional consortium of congenital heart surgery centres in Florida under the framework of the Children’s Medical Services has allowed for inter-institutional collaboration with the goal of quality improvement. This experience demonstrates, first, that the database maintained by the Society of Thoracic Surgeons can provide the framework for regional analysis of outcomes, and second, that voluntary regional collaborative efforts permit the pooling of data for such analysis.

The Correlation of Two Cerebral Saturation Monitors With Jugular Bulb Oxygen Saturation in Children Undergoing Cardiopulmonary Bypass for Congenital Heart Surgery

2016 ◽  
Vol 32 (10) ◽  
pp. 603-608 ◽  
Author(s):  
Aymen N. Naguib ◽  
Peter D. Winch ◽  
Roby Sebastian ◽  
Daniel Gomez ◽  
Luisa Guzman ◽  
...  
Keyword(s):  
Infrared Spectroscopy ◽  
Cardiopulmonary Bypass ◽  
Oxygen Saturation ◽  
Congenital Heart ◽  
Heart Surgery ◽  
Near Infrared ◽  
Jugular Bulb ◽  
Congenital Heart Surgery ◽  
Cerebral Oxygen ◽  
Cerebral Saturation

Background: Near-infrared spectroscopy (NIRS) is a noninvasive monitoring technique that measures regional cerebral oxygen saturation (rSO2). Objectives: The primary aim was to compare the output of 2 NIRS-based cerebral oximetry devices, FORESIGHT (CAS Medical Systems Inc, Branford, Connecticut) and INVOS (Covidien, Boulder, Colorado), to venous oxygen saturations from the jugular venous bulb at cannulation and decannulation of the superior vena cava (SVC). Secondary objectives included evaluating correlations of cerebral saturation, as measured by the NIRS devices, with mean arterial blood pressure (MAP), measured by an invasive arterial line, and end-tidal CO2 (ETCO2). Methods: Near-infrared spectroscopy, MAP, and ETCO2 data were collected at 13 defined events during each case when hemodynamic instability was expected. At SVC cannulation and decannulation, a 0.1 mL sample of blood was collected from the jugular bulb by the surgeon using a long angiocatheter. The oxygen saturation of these blood samples was measured using an AVOX device and compared with contemporaneous readings from the NIRS probes. Mixed-effects linear regression was used to correlate MAP or ETCO2 with cerebral oxygen saturation (by NIRS) at each time point. Results: Children undergoing cardiopulmonary bypass for congenital heart surgery (n = 34) were enrolled in the study. At SVC cannulation, both INVOS ( r = .78) and FORESIGHT ( r = .59) were correlated with AVOX data at P < .001, although the correlation with INVOS was significantly stronger ( P = .003). At SVC decannulation, INVOS ( r = .68; P < .001) and FORESIGHT ( r = .60; P < .001) were similarly correlated with jugular venous rSO2. Correlations of rSO2 (by NIRS) with MAP and ETCO2 levels were stronger than correlations between rSO2 change and change in MAP or ETCO2. Conclusion: INVOS correlated more strongly than FORESIGHT with the jugular bulb rSO2 at SVC cannulation but may have underestimated oxygen saturation at low rSO2 values. Data from both NIRS devices were correlated with MAP and ETCO2 over the case duration.

A National Survey: Current Clinical Practice in Pediatric Anesthesia for Congenital Heart Surgery

2020 ◽  
Vol 11 (3) ◽  
pp. 257-264
Author(s):  
Torsten Baehner ◽  
Nicholas Kiefer ◽  
Shahab Ghamari ◽  
Ingo Graeff ◽  
Christopher Huett ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Congenital Heart ◽  
Heart Surgery ◽  
Anesthetic Management ◽  
Pediatric Anesthesia ◽  
Congenital Heart Surgery ◽  
Online Questionnaire ◽  
Volatile Agent ◽  
Congenital Cardiac Surgery ◽  
First Choice

Background: Providing anesthesia for pediatric patients undergoing congenital cardiac surgery is complex and requires profound knowledge and clinical experience. Prospective studies on best anesthetic management are missing, partially due to different standards. The aim of the present study was to survey the current standard practice in anesthetic management in pediatric cardiac surgical centers in Germany. Methods: All 78 cardiac surgical centers in Germany were reviewed for a congenital cardiac surgery program. Centers with an active program for congenital cardiac surgery were interviewed to participate in the present online questionnaire to assess their current anesthetic practice. Results: Twenty-seven German centers running an active program for congenital heart surgery were identified, covering more than 3,000 pediatric cardiac surgeries annually. Of these centers, 96.3% (26/27) participated in our survey. Standard induction agents were etomidate in 26.9% (7/26), propofol in 19.2% (5/26), a combination of benzodiazepines and ketamine in 19.2% (5/26), and barbiturates in 11.5% (3/26). General anesthesia was preferentially maintained using volatile agents, 61.5% (16/26), with sevoflurane being the most common volatile agent within this group, 81.2% (13/16). Intraoperative first-choice/first-line inotropic drug was epinephrine, 53.8% (14/26), followed by milrinone, 23.1% (6/26), and dobutamine 15.4% (4/26). Fast-track programs performing on-table extubation depending on the type of surgical procedure were established at 61.5% (16/26) of the centers. Conclusion: This study highlights the diversity of clinical standards in pediatric cardiac anesthesia for congenital cardiac surgery in Germany.

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