Significant neonatal intraoperative cerebral and renal oxygen desaturation identified with near-infrared spectroscopy

A narrative review of the clinical applications of renal NIRS and integration with cerebral NIRS in the NICU

Organ perfusion and regional tissue oxygen saturation (rSO2) can be measured non-invasively using near-infrared spectroscopy (NIRS). While cerebral NIRS monitoring in neonates has been widely used, the adoption of renal NIRS is still evolving. This narrative review explores the application of renal NIRS in neonates and proposes an algorithm for integrating renal and cerebral NIRS in the neonatal intensive care unit. Decreased renal regional oxygenation (RrSO2) suggests decreased renal O2 delivery/perfusion or increased O2 consumption, warranting evaluation for acute kidney injury, anemia, hemodynamically significant patent ductus arteriosus, or hypotension. Increased RrSO2 indicates increased renal O2 delivery/perfusion or decreased O2 consumption, necessitating assessment for hyperoxia or established kidney injury. Combining cerebral and renal NIRS provides a comprehensive evaluation, allowing for the detection of early clinical changes. This integrated monitoring approach holds promise for improving neonatal outcomes. However, further large-scale studies are needed to establish normal ranges and guide therapeutic interventions.

Surgical Management of Wilms Tumors with Intravenous Extension: A Multicenter Analysis of Clinical Management with Technical Insights

BACKGROUND

About 5% of Wilms tumors present with vascular extension, which sometimes extends to the right atrium. Vascular extension does not affect the prognosis, but impacts the surgical strategy, which is complex and not fully standardized. Our goal is to identify elements of successful surgical management of Wilms tumors with vascular extensions.

PATIENTS AND METHODS

A retrospective study of pediatric Wilms tumors treated at three sites (January 1999-June 2019) was conducted. The inclusion criterion was the presence of a renal vein and vena cava thrombus at diagnosis. Tumor stage, pre and postoperative treatment, preoperative imaging, operative report, pathology, operative complications, and follow-up data were reviewed.

RESULTS

Of the 696 pediatric patients with Wilms tumors, 69 (9.9%) met the inclusion criterion. In total, 24 patients (37.5%) had a right atrial extension and two presented with Budd-Chiari syndrome at diagnosis. Two died at diagnosis owing to pulmonary embolism. All patients received neoadjuvant chemotherapy and thrombus regressed in 35.6% of cases. Overall, 14 patients had persistent intra-atrial thrombus extension (58%) and underwent cardiopulmonary bypass. Most thrombi (72%) were removed intact with nephrectomy. Massive intraoperative bleeding occurred during three procedures. Postoperative renal insufficiency was identified as a risk factor for patient survival (p = 0.01). With a median follow-up of 9 years (range: 0.5-20 years), overall survival was 89% and event-free survival was 78%.

CONCLUSIONS

Neoadjuvant chemotherapy with proper surgical strategy resulted in a survival rate comparable to that of children with Wilms tumors without intravascular extension. Clinicians should be aware that postoperative renal insufficiency is associated with worse survival outcomes.

Intraoperative Regional Cerebral Oxygenation During Pediatric Thoracoscopic Surgery: A Systematic Review

Background: Ventilating a pediatric patient during thoracoscopy is challenging. Few studies have highlighted the impact of capnothorax in children by measuring regional cerebral oxygen saturation (rcSO2) with near infrared spectroscopy. In this systematic review, we aimed to summarize the data from relevant studies and assess whether thoracoscopy in children is associated with intraoperative pathological cerebral desaturation. Methods: The authors systematically searched four databases for relevant studies on the measurement of rcSO2 during pediatric thoracoscopic procedures. The primary outcome was the proportion of patients with pathological desaturation, that is, >20% decline in the intraoperative rcSO2. Risk of bias among the included studies was estimated using the Newcastle-Ottawa scale. Results: The systematic search resulted in 776 articles, of which 7 studies were included in the analysis. In total, 88 patients (99 procedures) with an age ranging from 0 days to 8.1 years were included. Of these, 43 (49%) patients were neonates. The included cohort had esophageal atresia and tracheoesophageal fistula (n = 26), long-gap esophageal atresia (n = 5), congenital diaphragmatic hernia (n = 14), and congenital pulmonary airway malformations and other conditions needing lung resection (n = 43). Of the total 99 procedures, pathological desaturation was noticed in 13 (13.1%, 95% confidence interval 7.2-21.4) of them. Upon quality assessment, most of the studies were weaker in the selection and comparability domains. Conclusion: In this review, pathological cerebral desaturation was noticed in 13.1% of the pediatric thoracoscopic procedures. However, due to limited methodological quality of the included studies, further randomized multicentric studies comparing rcSO2 in open versus thoracoscopic surgeries are needed to derive definitive conclusions.

The impact of intestinal atresia on educational and mental health outcomes in school-aged children: A case-control cohort study

PURPOSE

To assess real-world educational outcomes, neurodevelopmental disorders and mental health disorders in patients with intestinal atresia (IA) and compare these to outcomes to age-matched controls.

METHODS

We performed a retrospective case-control study of children with IA born between 1991 and 2017. We evaluated educational outcomes using an Early Developmental Instrument, Grades 3, 7 and 8 assessments, Grade 9 completion and performance, high school graduation, and neurodevelopmental and mental health disorders using International Classification of Diseases codes available from a population-based dataset.

RESULTS

We identified a total of 94 IA cases and 940 date-of-birth-matched controls. Cases with chromosomal anomalies were more likely to fail the Early Developmental Instrument (OR = 2.88, p = 0.037), Grade 8 reading (OR = 2.94, p = 0.043) and Grade 12 (OR = 3.25, p = 0.036); cases without chromosomal anomalies were at no greater risk than their peers of failing to meet expectations and did not have an increased risk of anxiety (OR = 0.48, p = 0.12), depression (OR = 0.74, p = 0.6) or hyperactivity disorder (OR = 1.92, p = 0.087).

CONCLUSIONS

Our study demonstrated that IA patients without chromosomal anomalies are not at higher risk of neurodevelopmental and mental health disorders than controls. These results will offer more accurate outcome predictions for parents of children with IA.

Retroperitoneoscopic Surgery in Children Does Not Cause Pathological Desaturation in Cerebral/Renal Oxygenation on Near-Infrared Spectroscopy Compared with Laparoscopic and Thoracoscopic Surgery

Introduction: Cerebral and renal regional oxygen saturation (C-rSO₂ and R-rSO₂, respectively) were monitored using near-infrared spectroscopy in pediatric patients (range: 0.3-14.3 years) during minimally invasive surgery (MIS) taking at least 3 hours performed by laparoscopy (Lap), thoracoscopy (Tho), or retroperitoneoscopy (Ret) from January 2019 to December 2021. Materials and Methods: Criteria compared were operative time, preoperative/intraoperative hemoglobin, blood loss, mean arterial pressure, arterial partial pressure of carbon dioxide (PaCO₂), peripheral oxygen saturation (SpO₂), C-rSO₂, and R-rSO₂. Pathological desaturation (PD) was defined as >20% decrease from baseline, and statistical significance as P < .05. Results: Subjects (n = 79) were similar for gender, age, and body mass index. MIS procedures were: Lap = 45, Tho = 20, Ret = 14; one Lap case required conversion for severe adhesions, not PD. Intraoperative PaCO₂ (mmHg) was significantly higher in Tho (maximum: 59.5 ± 17.0, minimum: 39.9 ± 7.5) versus Lap (maximum: 39.9 ± 5.1, minimum: 34.6 ± 3.9) and Ret (maximum: 37.8 ± 4.2, minimum: 35.0 ± 3.3); P < .0001 (maximum), P = .0013 (minimum). Minimum intraoperative SpO₂ was significantly lower in Tho (P < .0001). Mean operative times were significantly shorter in Tho (259 ± 114 minutes) versus Lap (433 ± 154 minutes) and Ret (342 ± 100 minutes); P < .0001, respectively. PD was absent during Ret (C-rSO₂: 0/14 = 0% and R-rSO₂: 0/14 = 0%). Differences in PD for Lap (C-rSO₂: 7/45 = 15.6% and R-rSO₂: 10/45 = 22.2%) and Tho (C-rSO₂: 9/20 = 45.0%, and R-rSO₂: 7/20 = 35.0%) were significant; P = .0028 for C-rSO₂ and P = .0497 for R-rSO₂. Hemoglobin and blood loss were similar. Conclusions: PD was absent during Ret, despite longer operative times. If Ret is indicated for a procedure, neurodevelopmental sequelae of MIS could be minimized.