Hybrid procedure of bilateral pulmonary artery banding and bilateral ductal stenting in an infant with aortic atresia and interrupted aortic arch

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109582/1/ccd25424.pd

Cardiac Juvenile Xanthogranuloma in an Infant Presenting with Pericardial Effusion

Juvenile xanthogranuloma is a rare histiocytic disorder of childhood mainly affecting skin and rarely deep soft tissues and viscera. We report a 2‐month‐old infant who presented with respiratory distress secondary to a large pericardial effusion associated with an epicardial mass. Excisional biopsy was performed and the mass was diagnosed as juvenile xanthogranuloma. The child is well without evidence of disease 8 months following the excision. The corresponding literature on juvenile xanthogranuloma with cardiac manifestations is reviewed.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/99091/1/chd688.pd

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

Prevalence and Risk Factors for Upper Airway Obstruction after Pediatric Cardiac Surgery

Objective To determine the prevalence of and risk factors for extrathoracic upper-airway obstruction after pediatric cardiac surgery. Study design A retrospective chart review was performed on 213 patients younger than 18 years of age who recovered from cardiac surgery in our multidisciplinary intensive care unit in 2012. Clinically significant upper-airway obstruction was defined as postextubation stridor with at least one of the following: receiving more than 2 corticosteroid doses, receiving helium-oxygen therapy, or reintubation. Multivariate logistic regression analysis was performed to determine independent risk factors for this complication. Results Thirty-five patients (16%) with extrathoracic upper-airway obstruction were identified. On bivariate analysis, patients with upper-airway obstruction had greater surgical complexity, greater vasoactive medication requirements, and longer postoperative durations of endotracheal intubation. They also were more difficult to calm while on mechanical ventilation, as indicated by greater infusion doses of narcotics and greater likelihood to receive dexmedetomidine or vecuronium. On multivariable analysis, adjunctive use of dexmedetomedine or vecuronium (OR 3.4, 95% CI 1.4-8) remained independently associated with upper-airway obstruction. Conclusion Extrathoracic upper-airway obstruction is relatively common after pediatric cardiac surgery, especially in children who are difficult to calm during endotracheal intubation. Postoperative upper-airway obstruction could be an important outcome measure in future studies of sedation practices in this patient population

Passive Peritoneal Drainage versus Pleural Drainage after Pediatric Cardiac Surgery

Background: We aimed to determine whether infants undergoing cardiac surgery would more efficiently attain negative fluid balance postoperatively with passive peritoneal drainage as compared to traditional pleural drainage. Methods: A prospective, randomized study including children undergoing repair of tetralogy of Fallot (TOF) or atrioventricular septal defect (AVSD) was completed between September 2011 and June 2013. Patients were randomized to intraoperative placement of peritoneal catheter or right pleural tube in addition to the requisite mediastinal tube. The primary outcome measure was fluid balance at 48 hours postoperatively. Variables were compared using t tests or Fisher exact tests as appropriate. Results: A total of 24 patients were enrolled (14 TOF and 10 AVSD), with 12 patients in each study group. Mean fluid balance at 48 hours was not significantly different between study groups, −41 ± 53 mL/kg in patients with periteonal drainage and −9 ± 40 mL/kg in patients with pleural drainage (P = .10). At 72 hours however, postoperative fluid balance was significantly more negative with peritoneal drainage, −52.4 ± 71.6 versus +2.0 ± 50.6 (P = .04). On subset analysis, fluid balance at 48 hours in patients with AVSD was more negative with peritoneal drainage as compared to pleural, −82 ± 51 versus −1 ± 38 mL/kg, respectively (P = .02). Fluid balance at 48 hours in patients with TOF was not significantly different between study groups. Conclusion: Passive peritoneal drainage may more effectively facilitate negative fluid balance when compared to pleural drainage after pediatric cardiac surgery, although this benefit is not likely universal but rather dependent on the patient’s underlying physiology

Platelet consumption during neonatal extracorporeal life support (ECLS)

This paper reports the results of a retrospective study of blood use and blood loss in 40 neonates during extracorporeal life support (ECLS). Immediately after onset of bypass 39±2.5ml platelets, 59.4±6.5ml packed red blood cells (PRBC) and 15.0±5.4ml fresh frozen plasma (FFP) per patient were needed. The average daily amount given per patient was 49.0±3.0ml of platelets and 48.0±3.4ml and 9.6±3.9ml of PRBC and FFP respectively. The 10 patients who had bleeding complications received 50.0±6.3ml/day of platelets compared to 49.0±3.4ml in the other patients. The majority of blood loss during the entire period of ECLS was from samples, averaging 43.0 ± 1.5ml/day. Neck wound drainage, 6.7±2.5ml/day per patient, lasted for the entire period.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/68887/2/10.1177_026765919200700106.pd

Large pseudoaneurysm following right ventricle to pulmonary artery homograft placement in an infant

Pseudoaneurysm (PSA) is a known but rare complication of the right ventricle to pulmonary artery (RV-PA) conduits. The patient's clinical presentation can be variable ranging from asymptomatic to potential rupture. We describe an unusual case of a massive PSA in an infant who underwent RV-PA pulmonary homograft placement after relief of right ventricular outflow tract obstruction