Fiberoptic monitoring of central venous oxygen saturation (PediaSat) in small children undergoing cardiac surgery: continuous is not continuous

Background: Monitoring of superior vena cava saturation (ScvO2) has become routine in the management of pediatric patients undergoing cardiac surgery. The objective of our study was to evaluate the correlation between continuous ScvO2 by the application of a fiber-optic oximetry catheter (PediaSat) and intermittent ScvO2 by using standard blood gas measurements. These results were compared to those obtained by cerebral near infrared spectroscopy (cNIRS). Setting: Tertiary pediatric cardiac intensive care unit (PCICU). Methods and main results: A retrospective study was conducted in consecutive patients who were monitored with a 4.5 or 5.5 F PediaSat catheter into the right internal jugular vein. An in vivo calibration was performed once the patient was transferred to the PCICU and re-calibration took place every 24 hours thereafter. Each patient had a NIRS placed on the forehead. Saturations were collected every 4 hours until extubation. Ten patients with a median age of 2.2 (0.13-8.5) years and a weight of 12.4 (3.9-24) kg were enrolled. Median sampling time was 32 (19-44) hours: 64 pairs of PediaSat and ScVO2 saturations showed a poor correlation (r=0.62, 95% CI 44-75; p<0.0001) and Bland Altman analysis for repeated measures showed an average difference of 0.34 with a standard deviation of 7,9 and 95% limits of agreement from -15 to 16. Thirty-six pairs of cNIRS and ScVO2 saturations showed a fair correlation (r=0.79, 95% CI 0.60-0.89; p<0.0001) an average difference of -1.4 with a standard deviation of 6 and 95% limits of agreement from -13 to 10. Analysis of median percentage differences between PediaSat and ScvO2 saturation over time revealed that, although not statistically significant, the change in percentage saturation differences was clinically relevant after the 8th hour from calibration (from -100 to +100%). Conclusion: PediaSat catheters showed unreliable performance in our cohort. It should be further investigated whether repeating calibrations every 8 hours may improve the accuracy of this system. CNIRS may provide similar results with a lower invasiveness

High-dose fenoldopam reduces postoperative neutrophil gelatinase-associated lipocaline and cystatin C levels in pediatric cardiac surgery

21714857 2011 11 17 1466-609X 15 3 2011 Crit Care High-dose fenoldopam reduces postoperative neutrophil gelatinase-associated lipocaline and cystatin C levels in pediatric cardiac surgery. R160 The aim of the study was to evaluate the effects of high-dose fenoldopam, a selective dopamine-1 receptor, on renal function and organ perfusion during cardiopulmonary bypass (CPB) in infants with congenital heart disease (CHD).A prospective single-center randomized double-blind controlled trial was conducted in a pediatric cardiac surgery department. We randomized infants younger than 1 year with CHD and biventricular anatomy (with exclusion of isolated ventricular and atrial septal defect) to receive blindly a continuous infusion of fenoldopam at 1 \u3bcg/kg/min or placebo during CPB. Perioperative urinary and plasma levels of neutrophil gelatinase-associated lipocaline (NGAL), cystatin C (CysC), and creatinine were measured to assess renal injury after CPB.We enrolled 80 patients: 40 received fenoldopam (group F) during CPB, and 40 received placebo (group P). A significant increase of urinary NGAL and CysC levels from baseline to intensive care unit (ICU) admission followed by restoration of normal values after 12 hours was observed in both groups. However, urinary NGAL and CysC values were significantly reduced at the end of surgery and 12 hours after ICU admission (uNGAL only) in group F compared with group P (P = 0.025 and 0.039, respectively). Plasma NGAL and CysC tended to increase from baseline to ICU admission in both groups, but they were not significantly different between the two groups. No differences were observed on urinary and plasma creatinine levels and on urine output between the two groups. Acute kidney injury (AKI) incidence in the postoperative period, as indicated by pRIFLE classification (pediatric score indicating Risk, Injury, Failure, Loss of function, and End-stage kidney disease level of renal damage) was 50% in group F and 72% in group P (P = 0.08; odds ratio (OR), 0.38; 95% confidence interval (CI), 0.14 to 1.02). A significant reduction in diuretics (furosemide) and vasodilators (phentolamine) administration was observed in group F (P = 0.0085; OR, 0.22; 95% CI, 0.07 to 0.7).The treatment with high-dose fenoldopam during CPB in pediatric patients undergoing cardiac surgery for CHD with biventricular anatomy significantly decreased urinary levels of NGAL and CysC and reduced the use of diuretics and vasodilators during CPB.Clinical Trial.Gov NCT00982527. Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Ges\uf9 Children's Hospital, Piazza S, Onofrio 4, 00165, Rome, Italy. [email protected] Ricci Zaccaria Z Luciano Rosa R Favia Isabella I Garisto Cristiana C Muraca Maurizio M Morelli Stefano S Di Chiara Luca L Cogo Paola P Picardo Sergio S eng ClinicalTrials.gov NCT00982527 Journal Article 20110629 England Crit Care 9801902 1364-8535 IM Crit Care. 2011;15(4):177 21861863 PMC3219034 2011413201151720116292011629201171602011716020117160epublishcc1029510.1186/cc1029521714857PMC321903

Evaluation of Endotoxemia After Pediatric Cardiac Surgery With the Endotoxin Activity Assay: An Exploratory Prospective Cohort Study

Children with congenital heart diseases undergoing surgery with cardiopulmonary bypass are exposed to a high risk of perioperative endotoxemia. The aim of our study was to prospectively evaluate endotoxin assay activity reference levels during the postoperative phase of infants undergoing cardiac surgery for congenital heart disease and to assess their association with perioperative variables and postoperative infections

Multisite Near Infrared Spectroscopy During Cardiopulmonary Bypass in Pediatric Patients

Multisite near infrared spectroscopy (NIRS) monitoring during pediatric cardiopulmonary bypass (CPB) has not been extensively validated. Although it might be rational to explore regional tissue saturation at different body sites (namely brain, kidney, upper body, lower body), conflicting results are currently provided by experience in children. The aim of our study was to evaluate absolute values of multisite NIRS saturation during CPB in a cohort of infants undergoing pediatric cardiac surgery to describe average differences between cerebral, renal, upper body (arm), and lower body (thigh) regional saturation. Furthermore, the correlation between cerebral NIRS and cardiac index (CI) at CPB weaning was evaluated. Twenty-five infants were enrolled: their median weight, age, and body surface area were 3.9 (3.3-6) kg, 111 (47-203) days, and 0.24 (0.22-0.33) m(2) , respectively. Median Aristotle score was 8 (6-10), and vasoactive inotropic score at CPB weaning was 16 (14-25). A total of 17\u2009430 data points were recorded by each sensor: two-way ANOVA showed that time (P\u2009<\u20090.0001) and site (P\u2009=\u20090.0001) significantly affected variations of NIRS values: however, if cerebral NIRS values are excluded, sensor site is no more significant (P\u2009=\u20090.184 in the no circulatory arrest [noCA] group and P\u2009=\u20090.42 in the circulatory arrest [CA] group). Analysis of NIRS saturation changes over time showed that, at all sites, average NIRS values increased after CPB start, even if the increase of cerebral saturation was less intense than other sites (P\u2009<\u20090.0001). Detailed analysis of interaction between site of NIRS measurement and time point showed that cerebral NIRS (ranging from 65 to 75%) was always significantly lower than that of other channels (P\u2009<\u20090.0001) that tended to be in the range of oversaturation (80-90%), especially during the CPB phase. Average cerebral NIRS values of patients who did not undergo circulatory arrest (CA) during CPB, 10 min after CPB weaning, were associated with average CI values with a significant correlation (r\u2009=\u20090.7, P\u2009=\u20090.003). In conclusion, during CPB, cerebral NIRS values are expected to remain constantly lower than somatic sensors, which instead tend to show similar elevated saturations, regardless of their position. Based on these results, positioning of noncerebral NIRS sensors during CPB without CA may be questioned

Whole blood assessment of neutrophil gelatinase-associated lipocalin versus pediatricRIFLE for acute kidney injury diagnosis and prognosis after pediatric cardiac surgery: Cross-sectional study

OBJECTIVE:: To assess the ability of a single whole blood neutrophil gelatinase-associated lipocalin measurement in predicting acute kidney injury occurrence, its severity, and the need for postoperative renal replacement therapy after pediatric cardiac surgery. DESIGN:: Single-center prospective cross-sectional study. SETTING:: Tertiary care pediatric cardiac intensive care unit. PATIENTS:: Consecutive children <1 yr old with congenital heart diseases undergoing cardiac surgery with cardiopulmonary bypass. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Neutrophil gelatinase-associated lipocalin levels were measured after pediatric cardiac intensive care unit admission. Pediatric score indicating level of renal damage by Risk, Injury, Failure, Loss of function and End-stage kidney disease (pRIFLE) was used as the reference method. Acute kidney injury was diagnosed in 90 (56%) of the 160 enrolled patients. The number of abnormal neutrophil gelatinase-associated lipocalin samples (above the cutoff level of 150 ng/mL) was 12 over 90 (13%) in acute kidney injury population and 6 over 70 in non-acute kidney injury patients (8%) (odds ratio 1.6; 95% confidence interval 0.6-4.7; p = .31). Sensitivity of neutrophil gelatinase-associated lipocalin for acute kidney injury detection was 0.13 and specificity 0.91. The number of patients with abnormal neutrophil gelatinase-associated lipocalin samples was not significantly different within pediatric score indicating level of renal damage by pRIFLE (p = .69); furthermore, we found abnormal neutrophil gelatinase-associated lipocalin levels in 4 (30%) over 13 renal replacement therapy patients and in 14 (10%) over 133 children without renal replacement therapy need (odds ratio 4.2; 95% confidence interval 1.2-10.2; p = .02). Mean cross-clamp time (p = .28), inotropic score (p = .19), surgical risk score (p = .3), mean length of mechanical ventilation (p = .48), and pediatric cardiac intensive care unit stay (p = .57) did not significantly differ between children with abnormal and normal neutrophil gelatinase-associated lipocalin values. CONCLUSIONS:: Neutrophil gelatinase-associated lipocalin measured at pediatric cardiac intensive care unit arrival does not accurately predict acute kidney injury diagnosis, according to pediatric score indicating level of renal damage by pRIFLE classification. In these patients, neutrophil gelatinase-associated lipocalin might be helpful for renal replacement therapy predictio

Furosemide versus ethacrynic acid in pediatric patients undergoing cardiac surgery: a randomized controlled trial

Clinical effects of furosemide (F) and ethacrynic acid (EA) continuous infusion on urine output (UO), fluid balance, and renal, cardiac, respiratory, and metabolic function were compared in infants undergoing surgery for congenital heart diseases

Effects of Adjuvants for Human Use in Systemic Lupus Erythematosus (Sle)-Prone (Nzb/Nzw) F1 Mice

The safety of four different adjuvants was assessed in lupus-prone New Zealand black/New Zealand white (BW)F1 mice. Four groups of mice were injected intraperitoneally with incomplete Freund's adjuvant (IFA), complete Freund's adjuvant (CFA), squalene (SQU) or aluminium hydroxide (ALU). An additional group received plain phosphate-buffered saline (PBS) (UNT group). Mice were primed at week 9 and boosted every other week up to week 15. Proteinuria became detectable at weeks 17 (IFA group), 24 (CFA group), 28 (SQU and ALU groups) and 32 (UNT group). Different mean values were obtained among the groups from weeks 17 to 21 [week 17: one-way analysis of variance (anova) P = 0·016; weeks 18 and 19: P = 0·048; weeks 20 and 21: P = 0·013] being higher in the IFA group than the others [Tukey's honestly significant difference (HSD) post-test P < 0·05]. No differences in anti-DNA antibody levels were observed among groups. Anti-RNP/Sm antibody developed at week 19 in only one CFA-treated mouse. Mean mouse weight at week 18 was lower in the ALU group than the IFA (Tukey's HSD post-test P = 0·04), CFA (P = 0·01) and SQU (P < 0·0001) groups, while the mean weight in the SQU group was higher than in the IFA (P = 0·009), CFA (P = 0·013) and UNT (P = 0·005) groups. The ALU group weight decreased by almost half between weeks 29 and 31, indicating some toxic effect of ALU in the late post-immunization period. Thus, SQU was the least toxic adjuvant as it did not (i) accelerate proteinuria onset compared to IFA; (ii) induce toxicity compared to ALU or (iii) elicit anti-RNP/Sm autoantibody, as occurred in the CFA group

Neurologic injury in neonates with congenital heart disease during extracorporeal membrane oxygenation: an analysis of extracorporeal life support organization registry data

The aim of this article is to describe the epidemiology and factors associated with acute neurologic injury in neonates with congenital heart disease (CHD) undergoing extracorporeal membrane oxygenation (ECMO). It is a retrospective cohort study. Multi-institutional data for purposes of this study were obtained from the extracorporeal life support organization registry Neonates with CHD supported with ECMO during 2005-2010. Of 1,898 neonates with CHD supported with ECMO, 273 (14%) had neurologic injury. Birth weight less than 3 kg (odds ratio [OR]: 1.5; 95% confidence intervals [CI]: 1.1-1.9), pre-ECMO blood pH 64 7.15 (OR: 1.5, 95% CI: 1.1-2.1) need for cardiopulmonary resuscitation before ECMO (OR: 1.7, 95% CI: 1.5-2.0) increased neurologic injury. In-hospital mortality was higher in patients with neurologic injury compared with those without (73% vs. 53%; p < 0.001). Neonates with CHD undergoing ECMO are highly vulnerable to acute neurologic injury regardless of cardiac lesion-specific physiology or the occurrence of cardiac surgery. The incidence of neurologic injuries in this population is higher in sicker patients. Severity of illness should therefore become the main target for improvement. Timely deployment of ECMO may therefore influence the development of ECMO complications