Dexamethasone reduces the inflammatory response to cardiopulmonary bypass in children

Efficacy of perioperative prophylactic administration of corticosteroids in pediatric cardiac surgeries using cardiopulmonary bypass: a systematic review with meta-analysis

An updated systematic review with meta-analysis comparing perioperative prophylactic administration of corticosteroids with placebo in pediatric cardiac surgeries using cardiopulmonary bypass was conducted. The Cochrane Central Register of Controlled Trials and MEDLINE (via PubMed) were searched for relevant randomized controlled trials published between January 1, 2000, and February 14, 2023. The primary outcome was postoperative in-hospital mortality. Secondary outcomes were duration of mechanical ventilation, length of intensive care unit and hospital stay, postoperative low cardiac output syndrome, and adverse events. A total of 11 studies were included in the meta-analysis. Corticosteroid administration did not decrease postoperative in-hospital mortality compared with placebo (relative risk, 0.69; 95% confidence interval, 0.40-1.17). Subgroup analyses according to the type of corticosteroids and neonates revealed that corticosteroids did not decrease postoperative in-hospital mortality. In the trial sequential analysis, the last point in the z-curve was within the futility borders. Although the duration of mechanical ventilation (mean difference, -5.54 h; 95% confidence interval (CI), -9.75 - -1.34) and incidence of low cardiac output syndrome (relative risk, 0.75; 95% CI, 0.59 - 0.96) decreased with corticosteroid administration, it did not affect the length of intensive care unit (mean difference, -0.28 days; 95% CI, -0.74 - 0.17) and hospital stay (mean difference, -0.59 days; 95% CI, -1.31 - 0.14). In conclusion, perioperative prophylactic corticosteroid administration in pediatric cardiac surgeries using cardiopulmonary bypass did not decrease postoperative in-hospital mortality compared with placebo. According to the trial sequential analysis results, additional randomized controlled trials assessing mortality are not required. PROSPERO REGISTRY NUMBER: CRD 42023391789.

Perioperative prophylactic corticosteroids for cardiac surgery in children: A systematic review and meta-analysis

OBJECTIVE

Perioperative corticosteroids have been used for pediatric cardiac surgery for decades, but the underlying evidence is conflicting. We aimed to investigate the efficacy and safety of perioperative prophylactic corticosteroids in pediatric heart surgeries.

METHODS

We searched electronic databases until March 2023 to retrieve all randomized controlled trials (RCTs) that administered perioperative prophylactic corticosteroids to children undergoing heart surgery. We used RevMan 5.4 to pool risk ratios (RRs) and mean differences (MDs).

RESULTS

A total of 12 RCTs (2,209 patients) were included in our review. Corticosteroids administration was associated with a nonsignificant reduction in all-cause mortality (RR 0.62; 95% CI: 0.37-1.02, I2 = 0%; moderate certainty); however, it was associated with a lower duration of mechanical ventilation (MV) (MD -0.63 days; 95% CI: -1.16 to -0.09 days, I2 = 41%; high certainty). Corticosteroids did not affect the length of ICU and hospital stay but significantly reduced the incidence of postoperative low cardiac output syndrome (LCOS) (RR 0.76; 95% CI: 0.60-0.96, I2 = 0%; moderate certainty) and reoperation (RR 0.37; 95% CI: 0.19-0.74, I2 = 0%; moderate certainty). There was no increase in adverse events except a higher risk of hyperglycemia and postoperative insulin use.

CONCLUSIONS

The use of perioperative corticosteroids in pediatric heart surgeries is associated with a trend toward reduced all-cause mortality without attaining statistical significance. Corticosteroids reduced MV duration, and probably decrease the incidence of LCOS, and reoperations. The choice of corticosteroid agent and dose is highly variable and further larger studies may help determine the ideal agent, dose, and patient population for this prophylactic therapy.

Haemodynamic effects of prophylactic post-operative hydrocortisone following cardiopulmonary bypass in neonates undergoing cardiac surgery

Multiple studies have endeavoured to define the role of steroids in paediatric congenital heart surgery; however, steroid utilisation remains haphazard. In September, 2017, our institution implemented a protocol requiring that all neonates undergoing cardiac surgery with the use of cardiopulmonary bypass receive a five-day post-operative hydrocortisone taper. This single-centre retrospective study was designed to test the hypothesis that routine post-operative hydrocortisone administration reduces the incidence of capillary leak syndrome, leads to favourable postoperative fluid balance, and less inotropic support in the early post-operative period. Data were gathered on all term neonates who underwent cardiac surgery with the use of bypass between September, 2015 and 2019. Subjects who were unable to separate from bypass, required long-term dialysis, or long-term mechanical ventilation were excluded. Seventy-five patients met eligibility criteria (non-hydrocortisone group = 52; hydrocortisone group = 23). For post-operative days 0-4, we did not observe a significant difference in net fluid balance or vasoactive inotropic score between study groups. Similarly, we saw no major difference in secondary clinical outcomes (post-operative duration of mechanical ventilation, ICU/hospital length of stay, and time from surgery to initiation of enteral feeds). In contrast to prior analyses, our study was unable to demonstrate a significant difference in net fluid balance or vasoactive inotropic score with the administration of a tapered post-operative hydrocortisone regimen. Similarly, we saw no effect on secondary clinical outcomes. Further long-term randomised control studies are necessary to validate the potential clinical benefit of utilising steroids in paediatric cardiac surgery, especially in the more fragile neonatal population.

Cardiac surgery-associated acute kidney injury in newborns: A meta-analysis

<b>Introduction</b>: Acute kidney injury is a common complication following pediatric heart surgery, and it has been linked to an increased risk of morbidity and fatality.<br /> <b>Methods</b>: The PubMed and Medline databases were combed for relevant research until May 2022. The terms [Cardiac surgery] AND [acute renal injury] AND [newborns OR children OR neonates] AND [randomized control studies OR randomized control trials] were used as search criteria. The studies that met the inclusion criteria were considered qualified using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.<br /> <b>Results</b>: A total of 2,941 newborns or children were enrolled in 14 studies, with 931 developing acute renal damage. 2,095 of the enrolled infants and children received steroid, aminophylline, dexmedetomidine, and acetaminophen therapies. In seven studies, the odds ratio for steroids was not significantly different from control. In contrast, two studies comparing aminophylline to a control group found no statistically significant change. Two studies found no significant difference in dexmedetomidine therapy compared to control. Three trials, however, found a significant difference between the acetaminophen treatment and control groups.<br /> <b>Conclusion</b>: Acetaminophen was linked to a decreased risk of postoperative acute renal injury, while steroids had no benefit and aminophylline treatment could be justified.

Common Inflammatory Markers and Outcome After Pediatric Cardiac Surgery With High Thoracic Epidural Anesthesia: A Randomized Controlled Study

Background: High thoracic epidural analgesia (HTEA) plays a pivotal role in reducing stress and neuroendocrine response in cardiac surgeries. Aim: The primary objective is to assess the effect of HTEA, in pediatric cardiac surgery, on inflammatory markers (interleukin [IL]-6, IL-8, and tumor necrosis factor-α). The secondary objectives are to assess its effect on various organ systems, that is, pulmonary (PaO2, P/F ratio), renal (Creatinine clearance, somatic near infrared spectroscopy [NIRS], serum neutrophil gelatinase-associated lipocalin values), cardiac (cardiac index, serum Trop-I, and lactate levels), mechanical ventilation duration, and length of stay in hospital (LOS). Methods: The study included 188 pediatric patients, who underwent, on-pump cardiac surgery randomized into the Epidural Group (n = 92) and Non-Epidural Group (n = 96). After general anesthesia, a 23 G epidural catheter was placed at the T4-5 level with a Bupivacaine infusion while the Non-epidural Group received fentanyl infusion. Blood samples were collected at four-time points, T0(preop), T1(4 h), and on the first and second postoperative days (T2 and T3). Results: The inflammatory markers were reduced, while the outcomes variables of mechanical ventilation (MV) duration had lower values in the epidural group (19.5 h vs 47.3 h, P = .002). LOS was shorter (10.1 days vs 13.3 days, P = .016). pO2, PF ratio, and renal NIRS values were better in the Epidural Gp, while other parameters were comparable. Non-epidural Gp had more complications esp. Acute kidney injury requires RRT. Conclusion: HTEA use in pediatric, on-pump cardiac surgery offers a favorable profile in terms of reduction in the inflammatory markers and positive effect on the organ systems with lesser MV duration and the LOS.

Corticosteroids in patients undergoing cardiac surgery: A meta-analysis of 12,559 patients

OBJECTIVE

Corticosteroids can attenuate the inflammatory response to cardiopulmonary bypass, but their benefits on clinical outcomes are unclear. We conducted a meta-analysis to evaluate whether corticosteroid therapy affects outcomes in patients undergoing cardiac surgery.

METHODS

We searched PubMed, Embase, EBSCO and Cochrane databases from 1 January 2010 to 14 March 2022 for randomized controlled trials (RCTs) that assessed corticosteroid versus non- corticosteroid therapy in patients undergoing cardiac surgery. The primary outcome was in-hospital mortality. Secondary outcomes were renal failure, infection, delirium, intensive care unit (ICU) and hospital stay.

RESULTS

Four RCTs including 12,559 patients (6265 randomized to corticosteroid therapy and 6294 to non-corticosteroid therapy) were included. One-hundred and 92 of 6265 patients (3.1%) randomized to the corticosteroid group versus 221 of 6294 patients (3.5%) randomized to the non-corticosteroid group experienced death during hospitalization. Compared the control group, corticosteroid therapy did not significantly reduce in-hospital mortality, with an RR of 0.87 (0.72-1.06), p = .16. There was no difference in the incidence of infection (RR 0.78 (0.56-1.10), p = .16), delirium during hospitalization (RR 1.01 (0.90-1.14), p = .85), or the length of hospital stay (MD -0.13 (-0.32 to 0.05), p = .17). However, corticosteroid therapy significantly reduced the risk of renal failure ( RR 0.82 (0.67-0.99), p = .04), and the length of ICU stay (MD -0.41 (-0.65 to -0.17), p < .01).

CONCLUSIONS

Corticosteroids did not significantly reduce the rates of in-hospital mortality, infection, or delirium, but reduce the incidence of renal failure and the length of ICU stay.

Meta-Analysis: Shouldn't Prophylactic Corticosteroids be Administered During Cardiac Surgery with Cardiopulmonary Bypass?

Background

Corticosteroids can effectively inhibit systemic inflammation induced by cardiopulmonary bypass. Recently clinical trials and meta-analyses and current guidelines for cardiac surgery do not support corticosteroids prophylaxis during cardiac surgery because of an increase in myocardial infarction and no benefit for patients. The aim of this study is to determine whether specific corticosteroids dose ranges might provide clinical benefits without increasing myocardial infarction.

Methods

The PubMed, Web of Science, Embase, Clinical Trials, and Cochrane databases were searched for randomized controlled trials (RCTs) published before August 1, 2021.

Results

88 RCTs with 18,416 patients (17,067 adults and 1,349 children) were identified. Relative to placebo and high-dose corticosteroids, low-dose corticosteroids (≤20 mg/kg hydrocortisone) during adult cardiac surgery did not increase the risks of myocardial infarction (odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.43-2.17; p = 0.93). However, low-dose corticosteroids were associated with lower risks of atrial fibrillation (OR: 0.58, 95% CI: 0.44-0.76; p < 0.0001) and kidney injury (OR: 0.29, 95% CI: 0.09-0.96; p = 0.04). Furthermore, low-dose corticosteroids significantly shortened the mechanical ventilation times (mean difference [MD]: -2.74 h, 95% CI: -4.14, -1.33; p = 0.0001), intensive care unit (ICU) stay (MD: -1.48 days, 95% CI: -2.73, -0.22; p = 0.02), and hospital stay (MD: -2.29 days, 95% CI: -4.51, -0.07; p = 0.04).

Conclusion

Low-dose corticosteroids prophylaxis during cardiac surgery provided significant benefits for adult patients, without increasing the risks of myocardial infarction and other complications.

Uni-ventricular palliation vs. bi-ventricular repair: differential inflammatory response

Background

To examine whether uni-ventricular palliation (UVP) and bi-ventricular repair (BVR) result in a different pattern of systemic inflammatory response to pediatric cardiac surgery with extra-corporeal circulation (ECC).

Methods

In 20 children (median age 39.5 months) undergoing either UVP (n = 12) or BVR (n = 8), plasma levels of the inflammatory cytokines TNF-α, IL-6, IL-10, and IL-12 and of procalcitonin (PCT), were measured before, during and after open cardiac surgery up to postoperative day (POD) 10.

Results

Epidemiologic, operative- and outcome variables were similar in both groups but post-operative central venous pressure that was higher in UVP. In the whole cohort, the inflammatory response was characterized by an early important, significant and parallel increase of IL-6 and IL-10 that reached their peak values either at the end of ECC (IL-10) or 4 h postoperatively (IL-6), respectively and by a significant and parallel decrease of TNF-α and IL-12 levels after connection to ECC, followed by a bi-phasic significant increase with a first peak 4 h after ECC and a second at POD 10, respectively. Patients after UVP showed a shift of the cytokine balance with lower IL-6- (p = 0.01) after connection to ECC, lower early post-operative TNF-α - (p = 0.02) and IL-12- (p = 0.04) concentrations and lower TNF-α/IL-10-ratio (p = 0.03) as compared with patients with BVR. Levels of PCT were similar in both groups.

Conclusions

UVP is associated with an anti-inflammatory shift of the inflammatory response to cardiac surgery that might be related to the particular hemodynamic situation of patients with UVP.

The Current Status of Neuroprotection in Congenital Heart Disease

Neurological deficits are a serious and common sequelae of congenital heart disease (CHD). While their underlying mechanisms have not been fully characterized, their manifestations are well-known and understood to persist through adulthood. Development of therapies to address or prevent these deficits are critical to attenuate future morbidity and improve quality of life. In this review, we aim to summarize the current status of neuroprotective therapy in CHD. Through an exploration of present research in the pre-operative, intra-operative, and post-operative phases of patient management, we will describe existing clinical and bench efforts as well as current endeavors underway within this research area.

Strategies to Prevent Acute Kidney Injury after Pediatric Cardiac Surgery: A Network Meta-Analysis

BACKGROUND AND OBJECTIVES

AKI is a common complication after pediatric cardiac surgery and has been associated with higher morbidity and mortality. We aimed to compare the efficacy of available pharmacologic and nonpharmacologic strategies to prevent AKI after pediatric cardiac surgery.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

PubMed/MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists of relevant articles were searched for randomized controlled trials from inception until August 2020. Random effects traditional pairwise, Bayesian network meta-analyses, and trial sequential analyses were performed.

RESULTS

Twenty randomized controlled trials including 2339 patients and 11 preventive strategies met the eligibility criteria. No overall significant differences were observed compared with control for corticosteroids, fenoldopam, hydroxyethyl starch, or remote ischemic preconditioning in traditional pairwise meta-analysis. In contrast, trial sequential analysis suggested a 80% relative risk reduction with dexmedetomidine and evidence of <57% relative risk reduction with remote ischemic preconditioning. Nonetheless, the network meta-analysis was unable to demonstrate any significant differences among the examined treatments, including also acetaminophen, aminophylline, levosimendan, milrinone, and normothermic cardiopulmonary bypass. Surface under the cumulative ranking curve probabilities showed that milrinone (76%) was most likely to result in the lowest risk of AKI, followed by dexmedetomidine (70%), levosimendan (70%), aminophylline (59%), normothermic cardiopulmonary bypass (57%), and remote ischemic preconditioning (55%), although all showing important overlap.

CONCLUSIONS

Current evidence from randomized controlled trials does not support the efficacy of most strategies to prevent AKI in the pediatric population, apart from limited evidence for dexmedetomidine and remote ischemic preconditioning.

The Role of Deep Hypothermia in Cardiac Surgery

Hypothermia is defined as a decrease in body core temperature to below 35 °C. In cardiac surgery, four stages of hypothermia are distinguished: mild, moderate, deep, and profound. The organ protection offered by deep hypothermia (DH) enables safe circulatory arrest as a prerequisite to carrying out cardiac surgical intervention. In adult cardiac surgery, DH is mainly used in aortic arch surgery, surgical treatment of pulmonary embolism, and acute type-A aortic dissection interventions. In surgery treating congenital defects, DH is used to assist aortic arch reconstructions, hypoplastic left heart syndrome interventions, and for multi-stage treatment of infants with a single heart ventricle during the neonatal period. However, it should be noted that a safe duration of circulatory arrest in DH for the central nervous system is 30 to 40 min at most and should not be exceeded to prevent severe neurological adverse events. Personalized therapy for the patient and adequate blood temperature monitoring, glycemia, hematocrit, pH, and cerebral oxygenation is a prerequisite and indispensable part of DH.

Intraoperative methylprednisolone and neurodevelopmental outcomes in infants after cardiac surgery

BACKGROUND

Neurodevelopmental impairment is a significant consequence for survivors of surgery for critical congenital heart disease. This study sought to determine if intraoperative methylprednisolone during neonatal cardiac surgery is associated with neurodevelopmental outcomes at 12 months of age and to identify early prognostic variables associated with neurodevelopmental outcomes.

METHODS

A planned secondary analysis of a two-center, double-blind, randomized, placebo-controlled trial of intraoperative methylprednisolone in neonates undergoing cardiac surgery was performed. A brain injury biomarker was measured perioperatively. Bayley Scales of Infant and Toddler Development-III (BSID-III) were performed at 12 months of age. Two sample t-tests and generalized linear models were used.

RESULTS

There were 129 participants (n=61 methylprednisolone, n=68 placebo). There were no significant differences in BSID-III scores and brain injury biomarker levels between the two treatment groups. Participants who underwent a palliative (vs. corrective) procedure had lower mean BSID-III cognitive (101+15 vs. 106+14, p=0.03) and motor scores (85+18 vs. 94+16, p<0.01). Longer ventilation time was associated with lower motor scores. Longer cardiac intensive care unit (CICU) stay was associated with lower cognitive, language, and motor scores. Cardiopulmonary bypass time, aortic cross clamp time, and deep hypothermic circulatory arrest were not associated with BSID-III scores.

CONCLUSIONS

Neurodevelopmental outcomes were not associated with intraoperative methylprednisolone or intraoperative variables. Participants who underwent a neonatal palliative (vs. corrective) procedure had longer CICU stays and worse neurodevelopmental outcomes at 1 year. This work suggests that interventions focused solely on the operative period may not be associated with a long-term neurodevelopmental benefit.

Efficacy and safety of corticosteroids prophylaxis in cardiac surgery: A protocol for systematic review and meta-analysis

BACKGROUND

Although corticosteroid prophylaxis in adult cardiac surgery has been studied extensively for 40 years, its role remains controversial, and the optimal dose remains uncertain. The objective of this meta-analysis was to estimate the clinical benefits and risks of corticosteroid use in cardiopulmonary bypass.

METHODS

We will search Pubmed, Web of Science, Embase, Clinical Trials, and Cochrane Central Register of Controlled Trials for relevant clinical trials published in any language before August 1, 2020. Randomized controlled trials (RCTs) of interest which meet inclusion criteria published or unpublished will be included. We will divide the included studies into child and adult groups for analysis. If sufficient data are available, the included trials will be divided into 4 subgroups: ≤20 mg/kg (low dose), 20-40 mg/kg (slightly high dose), 40-100 mg/kg (high dose), and >100 mg/kg (ultra high dose) based on the equivalent hydrocortisone dose. INPLASY registration number: INPLASY2020100044.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

This study will compare the efficacy of tprophylactic corticosteroids for adults and children undergoing cardiac surgery with CPB. Due to the nature of the disease and intervention methods, randomized controlled trials may be inadequate, and we will carefully consider inclusion in high-quality, non-randomized controlled trials, but this may result in high heterogeneity and affect the reliability of the results.

Impact of Corticosteroids on Cardiopulmonary Bypass Induced Inflammation in Children: A Meta-Analysis

BACKGROUND

Corticosteroids suppress the inflammatory response to cardiopulmonary bypass in children undergoing cardiac surgery. What is less clear is the impact of corticosteroids on the postoperative course.

METHODS

A systematic review and meta-analysis was made of prospective randomized blinded placebo-controlled trials of pediatric patients who received corticosteroids or saline placebo before surgery was performed. Ten studies met inclusion criteria for a total of 768 patients. In a prespecified subgroup analysis, studies that either were limited to The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery congenital heart surgery mortality categories 1 and 2 or excluded neonates were eliminated and a secondary analysis was conducted, which consisted of seven studies and 555 patients.

RESULTS

Corticosteroids were associated with a significant improvement in fluid balance at 24 and 36 hours after surgery, with a mean difference of -15.2 mL/kg (95% confidence interval, 25.3 to -5.1 mL/kg; P < .01) and -5.7 mL/kg (95% confidence interval, -9.8 to -1.6 mL/kg; P < .01), respectively. Corticosteroids had no impact on the incidence of infection or mortality. With the secondary analysis, corticosteroids were associated with a trend toward significance in shortening the duration of mechanical ventilation (mean difference -0.7 days; 95% confidence interval, -1.7 to 0.1; P = .08).

CONCLUSIONS

Corticosteroids were found to have a favorable impact on postoperative fluid balance and may be associated with shortening the duration of mechanical ventilation. Although corticosteroids had no impact on mortality, they may be beneficial particularly for neonates and patients undergoing highly complex surgery.

Prophylactic corticosteroids for paediatric heart surgery with cardiopulmonary bypass

BACKGROUND

Corticosteroids are routinely given to children undergoing cardiac surgery with cardiopulmonary bypass (CPB) in an attempt to ameliorate the inflammatory response. Their use is still controversial and the decision to administer the intervention can vary by centre and/or by individual doctors within that centre.

OBJECTIVES

This review is designed to assess the benefits and harms of prophylactic corticosteroids in children between birth and 18 years of age undergoing cardiac surgery with CPB.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and Conference Proceedings Citation Index-Science in June 2020. We also searched four clinical trials registers and conducted backward and forward citation searching of relevant articles.

SELECTION CRITERIA

We included studies of prophylactic administration of corticosteroids, including single and multiple doses, and all types of corticosteroids administered via any route and at any time-point in the perioperative period. We excluded studies if steroids were administered therapeutically. We included individually randomised controlled trials (RCTs), with two or more groups (e.g. multi-drug or dose comparisons with a control group) but not 'head-to-head' trials without a placebo or a group that did not receive corticosteroids. We included studies in children, from birth up to 18 years of age, including preterm infants, undergoing cardiac surgery with the use of CPB. We also excluded studies in patients undergoing heart or lung transplantation, or both; studies in patients already receiving corticosteroids; in patients with abnormalities of the hypothalamic-pituitary-adrenal axis; and in patients given steroids at the time of cardiac surgery for indications other than cardiac surgery.

DATA COLLECTION AND ANALYSIS

We used the Covidence systematic review manager to extract and manage data for the review. Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We resolved disagreements by consensus or by consultation with a third review author. We assessed the certainty of evidence with GRADE.

MAIN RESULTS

We found 3748 studies, of which 888 were duplicate records. Two studies had the same clinical trial registration number, but reported different populations and interventions. We therefore included them as separate studies. We screened titles and abstracts of 2868 records and reviewed full text reports for 84 studies to determine eligibility. We extracted data for 13 studies. Pooled analyses are based on eight studies. We reported the remaining five studies narratively due to zero events for both intervention and placebo in the outcomes of interest. Therefore, the final meta-analysis included eight studies with a combined population of 478 participants. There was a low or unclear risk of bias across the domains. There was moderate certainty of evidence that corticosteroids do not change the risk of in-hospital mortality (five RCTs; 313 participants; risk ratio (RR) 0.83, 95% confidence interval (CI) 0.33 to 2.07) for children undergoing cardiac surgery with CPB. There was high certainty of evidence that corticosteroids reduce the duration of mechanical ventilation (six RCTs; 421 participants; mean difference (MD) 11.37 hours lower, 95% CI -20.29 to -2.45) after the surgery. There was high-certainty evidence that the intervention probably made little to no difference to the length of postoperative intensive care unit (ICU) stay (six RCTs; 421 participants; MD 0.28 days lower, 95% CI -0.79 to 0.24) and moderate-certainty evidence that the intervention probably made little to no difference to the length of the postoperative hospital stay (one RCT; 176 participants; mean length of stay 22 days; MD -0.70 days, 95% CI -2.62 to 1.22). There was moderate certainty of evidence for no effect of the intervention on all-cause mortality at the longest follow-up (five RCTs; 313 participants; RR 0.83, 95% CI 0.33 to 2.07) or cardiovascular mortality at the longest follow-up (three RCTs; 109 participants; RR 0.40, 95% CI 0.07 to 2.46). There was low certainty of evidence that corticosteroids probably make little to no difference to children separating from CPB (one RCT; 40 participants; RR 0.20, 95% CI 0.01 to 3.92). We were unable to report information regarding adverse events of the intervention due to the heterogeneity of reporting of outcomes. We downgraded the certainty of evidence for several reasons, including imprecision due to small sample sizes, a single study providing data for an individual outcome, the inclusion of both appreciable benefit and harm in the confidence interval, and publication bias.

AUTHORS' CONCLUSIONS

Corticosteroids  probably do not change the risk of mortality for children having heart surgery using CPB at any time point. They probably reduce the duration of postoperative ventilation in this context, but have little or no effect on the total length of postoperative ICU stay or total postoperative hospital stay. There was inconsistency in the adverse event outcomes reported which, consequently, could not be pooled. It is therefore impossible to provide any implications and policy-makers will be unable to make any recommendations for practice without evidence about adverse effects. The review highlighted the need for well-conducted RCTs powered for clinical outcomes to confirm or refute the effect of corticosteroids versus placebo in children having cardiac surgery with CPB. A core outcome set for adverse event reporting in the paediatric major surgery and intensive care setting is required.

Effect of Intraoperative Dexamethasone on Major Complications and Mortality Among Infants Undergoing Cardiac Surgery: The DECISION Randomized Clinical Trial

IMPORTANCE

Corticosteroids are widely used in pediatric cardiac surgery to blunt systemic inflammatory response and to reduce complications; nevertheless, their clinical efficacy is uncertain.

OBJECTIVE

To determine whether intraoperative administration of dexamethasone is more effective than placebo for reducing major complications and mortality during pediatric cardiac surgery.

DESIGN, SETTING, AND PARTICIPANTS

The Intraoperative Dexamethasone in Pediatric Cardiac Surgery was an investigator-initiated, double-blind, multicenter randomized trial that involved 4 centers in China, Brazil, and Russia. A total of 394 infants younger than 12 months, undergoing cardiac surgery with cardiopulmonary bypass were enrolled from December 2015 to October 2018, with follow-up completed in November 2018.

INTERVENTIONS

The dexamethasone group (n = 194) received 1 mg/kg of dexamethasone; the control group (n = 200) received an equivolume of 0.9% sodium chloride intravenously after anesthesia induction.

MAIN OUTCOMES AND MEASURES

The primary end point was a composite of death, nonfatal myocardial infarction, need for extracorporeal membrane oxygenation, need for cardiopulmonary resuscitation, acute kidney injury, prolonged mechanical ventilation, or neurological complications within 30 days after surgery. There were 17 secondary end points, including the individual components of the primary end point, and duration of mechanical ventilation, inotropic index, intensive care unit stay, readmission to intensive care unit, and length of hospitalization.

RESULTS

All of the 394 patients randomized (median age, 6 months; 47.2% boys) completed the trial. The primary end point occurred in 74 patients (38.1%) in the dexamethasone group vs 91 patients (45.5%) in the control group (absolute risk reduction, 7.4%; 95% CI, -0.8% to 15.3%; hazard ratio, 0.82; 95% CI, 0.60 to 1.10; P = .20). Of the 17 prespecified secondary end points, none showed a statistically significant difference between groups. Infections occurred in 4 patients (2.0%) in the dexamethasone group vs 3 patients (1.5%) in the control group.

CONCLUSIONS AND RELEVANCE

Among infants younger than 12 months undergoing cardiac surgery with cardiopulmonary bypass, intraoperative administration of dexamethasone, compared with placebo, did not significantly reduce major complications and mortality at 30 days. However, the study may have been underpowered to detect a clinically important difference.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02615262.

Corticosteroid Therapy in Neonates Undergoing Cardiopulmonary Bypass: Randomized Controlled Trial

BACKGROUND

The efficacy of intraoperative corticosteroids to improve outcomes following congenital cardiac operations remains controversial.

OBJECTIVES

The purpose of this study was to determine whether intraoperative methylprednisolone improves post-operative recovery in neonates undergoing cardiac surgery.

METHODS

Neonates undergoing cardiac surgery with cardiopulmonary bypass at 2 centers were enrolled in a double-blind randomized controlled trial of methylprednisolone (30 mg/kg) or placebo after the induction of anesthesia. The primary outcome was a previously validated morbidity-mortality composite that included any of the following events following surgery before discharge: death, mechanical circulatory support, cardiac arrest, hepatic injury, renal injury, or rising lactate level (>5 mmol/l).

RESULTS

Of the 190 subjects enrolled, 176 (n = 81 methylprednisolone, n = 95 placebo) were included in this analysis. A total of 27 (33%) subjects in the methylprednisolone group and 40 (42%) in the placebo group reached the primary study endpoint (odds ratio [OR]: 0.63; 95% confidence interval [CI]: 0.31 to 1.3; p = 0.21). Methylprednisolone was associated with reductions in vasoactive inotropic requirements and in the incidence of the composite endpoint in subjects undergoing palliative operations (OR: 0.38; 95% CI: 0.15 to 0.99; p = 0.048). There was a significant interaction between treatment effect and center. In this analysis, methylprednisolone was protective at 1 center, with an OR: 0.35 (95% CI: 0.15 to 0.84; p = 0.02), and not so at the other center, with OR: 5.13 (95% CI: 0.85 to 30.90; p = 0.07).

CONCLUSIONS

Intraoperative methylprednisolone failed to show an overall significant benefit on the incidence of the composite primary study endpoint. There was, however, a benefit in patients undergoing palliative procedures and a significant interaction between treatment effect and center, suggesting that there may be center or patient characteristics that make prophylactic methylprednisolone beneficial.

Louis J, Hammel J, Overman D, Blasiole B, Scott JP, Benscoter AL, Karamlou T, Ravekes WJ, Ofori-Amanfo G, Buckley JR, Zyblewski SC, McConnell P, Anderson BR, Santana-Acosta D, Eghtesady P, Bleiweis M, Swartz M, Butts RJ, Husain SA, Lambert L, Amula V, Eckhauser R, Griffiths E, Williams R, Witte M, Minich L. Rationale and design of the STeroids to REduce Systemic inflammation after infant heart Surgery (STRESS) trial

For decades, physicians have administered corticosteroids in the perioperative period to infants undergoing heart surgery with cardiopulmonary bypass (CPB) to reduce the postoperative systemic inflammatory response to CPB. Some question this practice because steroid efficacy has not been conclusively demonstrated and because some studies indicate that steroids could have harmful effects. STRESS is a randomized, placebo-controlled, double-blind, multicenter trial designed to evaluate safety and efficacy of perioperative steroids in infants (age < 1 year) undergoing heart surgery with CPB. Participants (planned enrollment = 1,200) are randomized 1:1 to methylprednisolone (30 mg/kg) administered into the CPB pump prime versus placebo. The trial is nested within the existing infrastructure of the Society of Thoracic Surgeons Congenital Heart Surgery Database. The primary outcome is a global rank score of mortality, major morbidities, and hospital length of stay with components ranked commensurate with their clinical severity. Secondary outcomes include several measures of major postoperative morbidity, postoperative hospital length of stay, and steroid-related safety outcomes including prevalence of hyperglycemia and postoperative infectious complications. STRESS will be one of the largest trials ever conducted in children with heart disease and will answer a decades-old question related to safety and efficacy of perioperative steroids in infants undergoing heart surgery with CPB. The pragmatic "trial within a registry" design may provide a mechanism for conducting low-cost, high-efficiency trials in a heretofore-understudied patient population.

Perioperative Corticosteroid Therapy in Children Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis

Background: The benefit-risk profile of perioperative corticosteroids in pediatric patients undergoing cardiac surgery remains controversial. Objective: To investigate the influence of perioperative corticosteroids on the postoperative mortality and clinical outcomes in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: We conducted a systematic search using MEDLINE, EMBASE, and Cochrane Database through August 31, 2019. We included randomized controlled trials comparing perioperative corticosteroids with other clinical interventions, placebo, or no treatment in children between 0 and 18 years of age undergoing cardiac surgery. The primary outcome of interest was all-cause in-hospital mortality. The secondary outcomes were length of intensive care unit stay (LOIS), duration of mechanical ventilation (DMV), postoperative insulin therapy, postoperative low cardiac output syndrome (LCOS), postoperative infection, maximal temperature (T _max) in the first 24 h postoperatively, urine output (UO) in the first 24 h postoperatively, serum lactate at postoperative day (POD) 1, blood glucose at POD 1, vasoactive inotrope score (VIS) at POD 1, and postoperative acute kidney injury (AKI). Study quality was assessed using the Cochrane Risk of Bias Assessment Tool. Results: Our analysis included 17 studies and 848 pediatric patients. The data demonstrated that children receiving corticosteroids showed no significant difference on the all-cause in-hospital mortality with a fixed-effect model (RR = 0.59, 95% CI = 0.28-1.25, P = 0.55) compared with controls. For the secondary outcomes, corticosteroids had a statistically significant reduction on the VIS at POD1 (MD = -2.04, 95% CI = -3.96 -0.12, P = 0.04), while it might be significantly associated with an increased blood glucose at POD1 (MD = 1.38, 95% CI = 0.68-2.09, P = 0.0001) and a 2.69-fold higher risk of postoperative insulin therapy (RR = 2.69, 95% CI = 1.37-5.27, P = 0.004). No statistical significance was shown in other secondary outcomes. Conclusion: Perioperative corticosteroids might not significantly improve clinical outcomes identified as mortality, LOIS, DMV, AKI, and LCOS other than VIS at POD1. However, it might increase the blood glucose and episodes of insulin therapy. Perioperative corticosteroids to attenuate the inflammatory response are not supported by available evidence from our study. Further results from ongoing randomized controlled trials with a larger sample size are required.

Acute Kidney Injury and Fluid Overload in Pediatric Cardiac Surgery

PURPOSE OF REVIEW

Acute kidney injury (AKI) and fluid overload affect a large number of children undergoing cardiac surgery, and confers an increased risk for adverse complications and outcomes including death. Survivors of AKI suffer long-term sequelae. The purpose of this narrative review is to discuss the short and long-term impact of cardiac surgery associated AKI and fluid overload, currently available tools for diagnosis and risk stratification, existing management strategies, and future management considerations.

RECENT FINDINGS

Improved risk stratification, diagnostic prediction tools and clinically available early markers of tubular injury have the ability to improve AKI-associated outcomes. One of the major challenges in diagnosing AKI is the diagnostic imprecision in serum creatinine, which is impacted by a variety of factors unrelated to renal disease. In addition, many of the pharmacologic interventions for either AKI prevention or treatment have failed to show any benefit, while peritoneal dialysis catheters, either for passive drainage or prophylactic dialysis may be able to mitigate the detrimental effects of fluid overload.

SUMMARY

Until novel risk stratification and diagnostics tools are integrated into routine practice, supportive care will continue to be the mainstay of therapy for those affected by AKI and fluid overload after pediatric cardiac surgery. A viable series of preventative measures can be taken to mitigate the risk and severity of AKI and fluid overload following cardiac surgery, and improve care.

Study protocol: NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC trial): a randomised controlled trial

INTRODUCTION

Congenital heart disease (CHD) is a major cause of infant mortality. Many infants with CHD require corrective surgery with most operations requiring cardiopulmonary bypass (CPB). CPB triggers a systemic inflammatory response which is associated with low cardiac output syndrome (LCOS), postoperative morbidity and mortality. Delivery of nitric oxide (NO) into CPB circuits can provide myocardial protection and reduce bypass-induced inflammation, leading to less LCOS and improved recovery. We hypothesised that using NO during CPB increases ventilator-free days (VFD) (the number of days patients spend alive and free from invasive mechanical ventilation up until day 28) compared with standard care. Here, we describe the NITRIC trial protocol.

METHODS AND ANALYSIS

The NITRIC trial is a randomised, double-blind, controlled, parallel-group, two-sided superiority trial to be conducted in six paediatric cardiac surgical centres. One thousand three-hundred and twenty infants <2 years of age undergoing cardiac surgery with CPB will be randomly assigned to NO at 20 ppm administered into the CPB oxygenator for the duration of CPB or standard care (no NO) in a 1:1 ratio with stratification by age (<6 and ≥6 weeks), single ventricle physiology (Y/N) and study centre. The primary outcome will be VFD to day 28. Secondary outcomes include a composite of LCOS, need for extracorporeal membrane oxygenation or death within 28 days of surgery; length of stay in intensive care and in hospital; and, healthcare costs. Analyses will be conducted on an intention-to-treat basis. Preplanned secondary analyses will investigate the impact of NO on host inflammatory profiles postsurgery.

ETHICS AND DISSEMINATION

The study has ethical approval (HREC/17/QRCH/43, dated 26 April 2017), is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12617000821392) and commenced recruitment in July 2017. The primary manuscript will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ACTRN12617000821392.

Comparative anti-thrombotic activity and haemorrhagic adverse effect of nattokinase and tissue-type plasminogen activator

Anti-thrombotic activity and safety of nattokinase, an enzyme produced by Bacillus subtilis during soybean fermentation, were investigated in comparison with tissue-type plasminogen activator (t-PA). Carotid arterial thrombosis was produced with a FeCl₃-soaked paper, followed by intravenous injection of nattokinase or t-PA. Nattokinase and t-PA delayed thrombus formation, near-fully (> 90%) inhibiting at 75 and 8.5 mg/kg, respectively. As adverse effects, t-PA induced petechial haemorrhage at 10 mg/kg in the lungs and thymus, and extensive bleeding at 20 mg/kg. Nattokinase also caused pulmonary haemorrhage from 300 mg/kg. Collectively, the standard safety margins (SSMs) for t-PA and nattokinase were calculated to be 1.2 and 4.0, respectively. Combinational treatment with dexamethasone (2 mg/kg) increased the efficacy and safety of t-PA and nattokinase, widening their SSMs to 2.4 and 8.0, respectively. The results indicate that nattokinase delayed thrombus formation and dissolved thrombi, and that nattokinase could be a good candidate anti-thrombotic agent with relatively-low haemorrhagic risk.

Adrenal insufficiency in neonates undergoing cardiopulmonary bypass and postoperative hypothalamic-pituitary-adrenal function after prophylactic glucocorticoids

OBJECTIVES

Determine incidence of preoperative adrenal insufficiency in neonates >35 weeks gestation with congenital heart disease undergoing cardiothoracic surgery with bypass and effects of prophylactic methylprednisolone on postoperative hypothalamic-pituitary-adrenal function and hemodynamic stability.

DESIGN

Prospective observational study in 36 neonates with preoperative adrenocorticotrophic hormone stimulation tests and serial total cortisol and adrenocorticotrophic hormone measurements before and after surgery. Data analyses: analysis of variance and regression.

RESULTS

Baseline circulating adrenocorticotrophic hormone and cortisol were unchanged 4-20 days postnatal (P > 0.1); however, cortisol levels rose with increasing adrenocorticotrophic hormone, P = 0.02. Ten neonates (29%) demonstrated preoperative adrenal insufficiency (∆cortisol ≤9 µg/dl); one had postoperative hemodynamic instability. Growth-restricted neonates had lower baseline cortisol, but normal stimulation tests and responded well to surgical stresses. Seventy-five percent of neonates receiving perioperative methylprednisolone demonstrated postoperative hypothalamic-pituitary-adrenal inhibition.

CONCLUSION

Adrenal insufficiency appears common in neonates >35 weeks gestation with congenital heart disease, but did not contribute to postoperative hemodynamic instability despite hypothalamic-pituitary-adrenal inhibition.

Effect of methylprednisolone on acute kidney injury in patients undergoing cardiac surgery with a cardiopulmonary bypass pump: a randomized controlled trial

BACKGROUND

Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery.

METHODS

We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 μmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery.

RESULTS

Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease.

INTERPRETATION

Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.

Pharmacological interventions for the prevention of acute kidney injury after pediatric cardiac surgery: a network meta-analysis

BACKGROUND

Acute kidney injury constitutes a major complication of cardiac surgery in pediatric patients. The present meta-analysis aims to accumulate current literature and assess the efficacy of pharmacological interventions in preventing postoperative renal dysfunction after congenital heart surgery.

METHODS

Literature search was conducted using Medline (1966-2018), Scopus (2004-2018), Cochrane Central Register of Controlled Trials CENTRAL (1999-2018), Clinicaltrials.gov (2008-2018), and Google Scholar (2004-2018) databases. Statistical analysis was performed with Review Manager 5.3 and R 3.4.3.

RESULTS

Meta-analysis included 14 studies, with a total of 2,625 patients. AKI incidence was significantly lower in the dexmedetomidine (OR 0.49, 95% CI [0.28-0.87]) and acetaminophen (OR 0.43, 94% CI [0.28-0.67]) groups, while no difference was present in patients receiving corticosteroid (OR 1.16, 95% CI [0.69-1.95]), fenoldopam (OR 0.47, 95% CI [0.22-1.02]), or aminophylline (OR 0.98, 95% CI [0.29-3.34]). Network meta-analysis proposed that dexmedetomidine had the greatest probability (44.5%) to rank first, although significant overlap with the other treatments was observed.

CONCLUSIONS

The present meta-analysis suggests that no firm evidence exists about the protective role of pharmacological interventions in the pediatric population. Future randomized controlled trials should clarify the effectiveness of dexmedetomidine and acetaminophen and indicate the optimal protocol to be applied, to protect renal function in the perioperative setting.

Steroids in paediatric heart surgery: eminence or evidence-based practice?

Steroids in paediatric heart surgery are given prophylactically to blunt the systemic inflammatory response induced by the extracorporeal circuit and to improve clinical outcomes. However, there is an ongoing controversy about the impact of steroids on clinical outcomes after paediatric heart surgery. The hypothalamic-pituitary-adrenal axis is the primary neuroendocrine system activated during the stress of surgery. Relative adrenal insufficiency can accompany paediatric heart surgery; therefore, perioperative steroid supplementation is still administered by some centres. The studies that investigate the hypothalamic-pituitary-adrenal axis physiology during surgery have many limitations, and it is unclear how to define what is adrenal insufficiency. In this review, we focus on discussing the available evidence for steroid use in paediatric cardiac surgery.

Prevention of Acute Kidney Injury in Children Undergoing Cardiac Surgery: A Narrative Review

Children undergoing cardiac surgery are at risk of developing acute kidney injury (AKI). Preventing cardiac surgery-associated AKI (CS-AKI) is important as it is associated with increased early- and long-term mortality and morbidity. Targeting modifiable risk factors (eg, avoiding poor renal perfusion, nephrotoxic drugs, and fluid overload) reduces the risk of CS-AKI. There is currently no strong evidence for the routine use of pharmacological approaches (eg, aminophylline, dexmedetomidine, fenoldopam, and steroids) to prevent CS-AKI. There is robust evidence to support the role of early peritoneal dialysis as a nonpharmacologic approach to prevent CS-AKI.

Corticosteroids and Other Anti-Inflammatory Strategies in Pediatric Heart Surgery: A National Survey of Practice

BACKGROUND

The role of steroids to mitigate the deleterious effects of pediatric cardiopulmonary bypass (CPB) remains a matter of debate; therefore, we aimed to assess preferences in administering corticosteroids (CSs) and the use of other anti-inflammatory strategies in pediatric cardiac surgery.

METHODS

A 19-question survey was distributed to consultants in pediatric cardiac anesthesia from 12 centers across the United Kingdom and Ireland.

RESULTS

Of the 37 respondents (37/60, 62%), 24 (65%) use CSs, while 13 (35%) do not use steroids at all. We found variability within 5 (41%) of the 12 centers. Seven consultants (7/24, 29%) administer CSs in every case, while 17 administer CSs in selected cases only (17/24, 71%). There was variability in the dose of steroid administration. Almost all consultants (23/24, 96%) administer a single dose at induction, and one administers a two-dose regimen (1/24, 4%). There was variability in CS indications. Most consultants (24/37, 66%) use modified ultrafiltration at the conclusion of CPB. Fifteen consultants (15/32, 47%) report the use of aprotinin, while only 3 use heparin-coated circuits (3/24, 9%).

CONCLUSIONS

We found wide variability in practice in the administration of CSs for pediatric cardiac surgery, both within and between units. While most anesthetists administer CSs in at least some cases, there is no consensus on the type of steroid, the dose, and at which patient groups this should be directed. Modified ultrafiltration is still used by most of the centers. Almost half of consultants use aprotinin, while heparin-coated circuits are infrequently used.

Neuroprotective Strategies in Repair and Replacement of the Aortic Arch

Aortic arch surgery is a technical challenge, and cerebral protection during distal anastomosis is a continued topic of controversy and discussion. The physiologic effects of hypothermic arrest and adjunctive cerebral perfusion have yet to be fully defined, and the optimal strategies are still undetermined. This review highlights the historical context, physiological rationale, and clinical efficacy of various neuroprotective strategies during arch operations.

Useful References in Pediatric Cardiac Intensive Care: The 2017 Update

OBJECTIVES

Pediatric cardiac intensive care continues to evolve, with rapid advances in knowledge and improvement in clinical outcomes. In the past, the Board of Directors of the Pediatric Cardiac Intensive Care Society created and subsequently updated a list of sentinel references focused on the care of critically ill children with congenital and acquired heart disease. The objective of this article is to provide clinicians with a compilation and brief summary of updated and useful references that have been published since 2012.

DATA SELECTION

Pediatric Cardiac Intensive Care Society members were solicited via a survey sent out between March 20, 2017, and April 28, 2017, to provide important references that have impacted clinical care. The survey was sent to approximately 523 members. Responses were received from 45 members, of which some included multiple references.

DATA EXTRACTION

Following review of the list of references, and removing editorials, references were compiled by the first and last author. The final list was submitted to members of the society's Research Briefs Committee, who ranked each publication.

DATA SYNTHESIS

Rankings were compiled and the references with the highest scores included. Research Briefs Committee members ranked the articles from 1 to 3, with one being highly relevant and should be included and 3 being less important and should be excluded. Averages were computed, and the top articles included in this article. The first (K.C.U.) and last author (K.M.G.) reviewed and developed summaries of each article.

CONCLUSIONS

This article contains a compilation of useful references for the critical care of children with congenital and acquired heart disease published in the last 5 years. In conjunction with the prior version of this update in 2012, this article may be used as an educational reference in pediatric cardiac intensive care.

Corticosteroids in Pediatric Heart Surgery: Myth or Reality

Background: Corticosteroids have been administered prophylactically for more than 60 years in pediatric heart surgery, however, their use remains a matter of debate. There are three main indications for corticosteroid use in pediatric heart surgery with the use of cardiopulmonary bypass (CPB): (1) to blunt the systemic inflammatory response (SIRS) induced by the extracorporeal circuit; (2) to provide perioperative supplementation for presumed relative adrenal insufficiency; (3) for the presumed neuroprotective effect during deep hypothermic circulatory arrest operations. This review discusses the current evidence behind the use of corticosteroids in these three overlapping areas. Materials and Methods: We conducted a structured research of the literature using PubMed and MEDLINE databases to November 2017 and additional articles were identified by cross-referencing. Results: The evidence suggests that there is no correlation between the effect of corticosteroids on inflammation and their effect on clinical outcome. Due to the limitations of the available evidence, it remains unclear if corticosteroids have an impact on early post-operative outcomes or if there are any long-term effects. There is a limited understanding of the hypothalamic-pituitary-adrenal axis function during cardiac surgery in children. The neuroprotective effect of corticosteroids during deep hypothermic circulatory arrest surgery is controversial. Conclusions: The utility of steroid administration for pediatric heart surgery with the use of CPB remains a matter of debate. The effect on early and late outcomes requires clarification with a large multicenter randomized trial. More research into the understanding of the adrenal response to surgery in children and the effect of corticosteroids on brain injury is warranted.

Efficacy of corticosteroids in prevention of acute kidney injury in neonates undergoing cardiac surgery-A randomized controlled trial

BACKGROUND

Heart surgery requiring cardiopulmonary bypass (CPB) causes an inflammatory response which may further induce acute kidney injury (AKI). In the present randomized controlled study we evaluated whether corticosteroids can prevent CPB related AKI in neonates undergoing heart surgery.

METHODS

Forty neonates were randomized to receive 2 mg/kg methylprednisolone followed by hydrocortisone infusion 0.2 mg/kg/h perioperatively with tapering doses for 5 days, or placebo administered in a similar fashion. The primary outcome was the inflammatory response (plasma concentrations of interleukins 6 and 10). The correspondence of the interleukin concentrations with AKI was analysed as secondary outcome. In addition, plasma and urine neutrophil gelatinase-associated lipocalin (NGAL), plasma cystatin C, and urine kidney injury molecule-1 (KIM-1) levels were measured.

RESULTS

Six patients (15%) developed post-operative AKI. No significant difference in the AKI occurrence between the treatment (n = 2) and the placebo (n = 4) groups could be found (risk ratio 2.00, 95% confidence interval 0.41-9.71; P = .661) despite significant reduction in inflammatory response in the treatment group. One patient in the treatment group and two patients in the placebo group required acute peritoneal dialysis. Plasma creatinine and cystatin C or urine NGAL and KIM-1 concentrations did not differ between the treatment and the placebo group.

CONCLUSIONS

Significantly reduced inflammatory reaction induced by corticosteroid treatment in neonates undergoing cardiac surgery did not reduce the incidence of AKI defined by KDIGO classification or decrease the rise of AKI biomarkers.

Neutrophil Phenotype Correlates With Postoperative Inflammatory Outcomes in Infants Undergoing Cardiopulmonary Bypass

OBJECTIVES

Infants with congenital heart disease frequently require cardiopulmonary bypass, which causes systemic inflammation. The goal of this study was to determine if neutrophil phenotype and activation status predicts the development of inflammatory complications following cardiopulmonary bypass.

DESIGN

Prospective cohort study.

SETTING

Tertiary care PICU with postoperative cardiac care.

PATIENTS

Thirty-seven patients 5 days to 10 months old with congenital heart disease requiring cardiopulmonary bypass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Laboratory and clinical data collected included length of mechanical ventilation, acute kidney injury, and fluid overload. Neutrophils were isolated from whole blood at three time points surrounding cardiopulmonary bypass. Functional analyses included measurement of cell surface protein expression and nicotinamide adenine dinucleotide phosphate oxidase activity. Of all patients studied, 40.5% displayed priming of nicotinamide adenine dinucleotide phosphate oxidase activity in response to N-formyl-Met-Leu-Phe stimulation 24 hours post cardiopulmonary bypass as compared to pre bypass. Neonates who received steroids prior to bypass demonstrated enhanced priming of nicotinamide adenine dinucleotide phosphate oxidase activity at 48 hours. Patients who displayed priming post cardiopulmonary bypass were 8.8 times more likely to develop severe acute kidney injury as compared to nonprimers. Up-regulation of neutrophil surface CD11b levels pre- to postbypass occurred in 51.4% of patients, but this measure of neutrophil priming was not associated with acute kidney injury. Subsequent analyses of the basal neutrophil phenotype revealed that those with higher basal CD11b expression were significantly less likely to develop acute kidney injury.

CONCLUSIONS

Neutrophil priming occurs in a subset of infants undergoing cardiopulmonary bypass. Acute kidney injury was more frequent in those patients who displayed priming of nicotinamide adenine dinucleotide phosphate oxidase activity after cardiopulmonary bypass. This pilot study suggests that neutrophil phenotypic signature could be used to predict inflammatory organ dysfunction.

High-dose methylprednisolone and endothelial glycocalyx in paediatric heart surgery

BACKGROUND

Corticosteroids are used in paediatric heart surgery to attenuate systemic inflammatory response. Glycocalyx regulates vascular permeability, shear stress and cell adhesion on the endothelium. Syndecan-1 serves as a biomarker of glycocalyx degradation. Hydrocortisone decreased endothelial glycocalyx degradation in an experimental model. Our hypothesis was that high-dose methylprednisolone decreases glycocalyx degradation as measured by plasma sydecan-1 concentration in children undergoing cardiac surgery.

METHODS

Two double-blinded, randomized, placebo-controlled trials were conducted. In the first trial ('neonatal trial'), 40 neonates undergoing open heart surgery received either 30 mg/kg intravenous methylprednisolone (n = 20) or placebo (n = 20). In the second trial ('VSD trial'), 45 infants and very young children, undergoing ventricular or atrioventricular septal defect correction received one of the following: 30 mg/kg of methylprednisolone intravenously after anaesthesia induction (n = 15), 30 mg/kg methylprednisolone in the cardiopulmonary bypass prime solution (n = 15) or placebo (n = 15). Plasma syndecan-1 concentrations were measured. Results were expressed both as absolute concentrations and in relative concentrations as multiples of the baseline values of syndecan-1.

RESULTS

There were no statistically significant differences between the neonate trial groups for absolute syndecan-1 concentrations. However, operative administration of methylprednisolone to neonates significantly reduced the relative increases of syndecan-1 at weaning from cardiopulmonary bypass (P = 0.008) and at 6 h post-operatively (P = 0.018). There were no statistically significant differences in absolute or relative increases of syndecan-1 between the VSD trial study groups.

CONCLUSION

High-dose methylprednisolone reduces shedding of glycocalyx in neonates after complex cardiac surgery but not in older infants after repair of VSD/AVSD with shorter ischaemia times.

Brain Monitoring and Protection During Pediatric Cardiac Surgery

With advances in medical care, survival after cardiac surgery for congenital heart disease has dramatically improved, and attention is increasingly focused on longterm functional morbidities, especially neurodevelopmental outcomes, with their profound consequences to patients and society. There are multiple reasons for concern about brain injury. Some cardiac defects are associated with brain anomalies and altered cerebral blood flow regulation. Brain imaging studies have demonstrated that injury to gray and white matter is quite frequent before heart surgery in neonates. Cardiopulmonary bypass and deep hypothermic circulatory arrest are associated with shortand longer-term adverse neurologic outcome. Additional brain injury can occur during the patient's recovery from surgery. Strategies to optimize neurologic outcome continue to evolve. With new technological developments, perioperative neurologic monitoring of small children has become easier, and data suggest these modalities usefully identify adverse neurologic events and might predict outcome. Monitoring methods to be discussed include processed electroencephalography, near infrared spectroscopy, and transcranial Doppler ultrasound. Alternative perfusion techniques to deep hypothermic circulatory arrest have been developed, such as regional antegrade cerebral perfusion during cardiopulmonary bypass. Other neuroprotective strategies employed during open-heart surgery include temperature regulation, acid-base management, degree of hemodilution, blood glucose control and anti-inflammatory therapies. Evidence of the impact of these measures on neurologic outcome is examined, and deficiencies in our current understanding of neurologic function in children with congenital heart disease are identified.

Cardiopulmonary Bypass-Induced Inflammatory Response: Pathophysiology and Treatment

OBJECTIVES

The objectives of this review are to discuss the pathophysiology of the pro-inflammatory response to the cardiopulmonary bypass circuit, the impact of ischemia reperfusion injury on post-operative organ function, the compensatory anti-inflammatory response and the evidence for immune-modulatory strategies and their impact on outcomes.

DATA SOURCE

MEDLINE, PubMed.

CONCLUSION

Innovations such as the development of more biocompatible surfaces and miniaturized circuits, as well as the increasing expertise of surgeons, anesthesiologists and perfusionists has transformed cardiac surgery and the use of cardiopulmonary bypass into a relatively routine procedure with favorable outcomes. Despite these refinements, the attendant inflammatory response to bypass, ischemia reperfusion injury and the compensatory anti-inflammatory response contribute to post-operative morbidity and mortality. Additional studies are needed to further delineate the impact of immunomodulatory strategies on outcomes.

Investigating the Impacts of Preoperative Steroid Treatment on Tumor Necrosis Factor-Alpha and Duration of Extubation Time underwent Ventricular Septal Defect Surgery

BACKGROUND

Cardiopulmonary bypass is known to cause inflammatory events. Inflammation occurs due to many known important biological processes. Numerous mechanisms are known to be responsible for the development of inflammatory processes. Currently, there are many defined mediators as a tumor necrosis factor-α (TNF-α) playing an active role in this process.

AIMS

This research was to investigate the effects of pre-operative steroid use on inflammatory mediator TNF-α and on time to extubation postoperatively in ventricular septal defect patients undergoing cardiopulmonary bypass surgery.

STUDY DESIGN

Controlled clinical study.

METHODS

This study included 30 patients. These patients were assigned into two groups, each containing 15 patients. 5 micrograms/kg methylprednisolone was injected intravenously 2 hours before the surgery to Group I, whereas there was no application to the patients in Group II. TNF-α (pg/mL) level was measured in arterial blood samples obtained at four periods including: the preoperative period (Pre TNF); at the 5(th) minute of cross-clamping (Per TNF); 2 hours after termination of cardiopulmonary bypass (Post TNF); and at the postoperative 24th hours in cardiovascular surgery intensive care unit (Post 24 h TNF).

RESULTS

The mean cross-clamp time was 66±40 and 55±27 minutes in Group I and Group II respectively. No significant difference was found between the groups in terms of cross-clamp time (p>0.05). The mean time to extubation was 6.1±2.3 hours in Group I and 10.6±3.4 hours in Group II. Group I extubation time was significantly shorter than Group II. Group I TNF-α levels at Post TNF and Post24h TNF was lower than Group II. These differences are also statistically significant (p<0.05).

CONCLUSION

There is a strong indication that preoperative steroid treatment reduced the TNF-α level together with shortens duration of postoperative intubation and positively contributes to extubation in ventricular septal defect patients operated in cardiac surgery with cardiopulmonary bypass. (ClinicalTrials.gov Identifier: TCTR20150930001).

Cerebral injury during paediatric heart surgery: perfusion issues

Suboptimal neurodevelopmental outcome is common in children who have congenital heart disease. Its aetiology is often multifactorial. This review focuses on the role of cardiopulmonary bypass. Hypothermia is the mainstay of cerebral protection. Low flow and regional low flow are preferred to deep hypothermic circulatory arrest in many situations. Cooling and rewarming, aortopulmonary collaterals, pH, air emboli, the systemic inflammatory response, haematocrit, oxygenation, glucose and ultrafiltration can influence neurodevelopmental outcome. Although no pharmacological agents have been shown to have a beneficial effect on neurodevelopmental outcome in clinical practice in children, animal work on the use of steroids several hours before surgery is encouraging.

Effect of modified ultrafiltration on the inflammatory response in paediatric open-heart surgery: a prospective, randomized study

Modified ultrafiltration (MUF) is often used in conjunction with paediatric cardiac surgery with cardiopulmonary bypass (CPB) and is thought to improve clinical outcome. It is unclear whether these improvements (if any) are due to the removal of inflammatory mediators. In this prospective study, 18 children aged 12-24 months undergoing uncomplicated cardiac surgery with methylprednisolone added in the pump prime were randomized to receive CPB with ( n= 10) and without ( n= 8) MUF. Cytokines (TNFα, IL-6, IL- 1β, IL-10, IL-1ra), complement split products (C3d, C4d) and coagulation system activation (F1+ 2, ATIII) were measured pre-, peri- and up to 48 h postoperatively. For clinical outcome, the alveolar-arterial oxygen (A-a) gradient, transfusion requirement, drain loss, mean blood pressure and requirement for inotropic support were registered up to 24 h postoperatively. Our results show an improvement in postoperative oxygenation as well as a tendency towards decreased drain loss and improved haemodynamics in the MUF group. There were no intergroup differences detectable for TNFα, IL-1β, IL-1ra, complement and coagulation markers. We conclude that MUF in itself does not significantly influence TNFα, IL-1β, IL-1ra and the complement and coagulation profiles in children undergoing cardiac surgerywith CPB. Despite this, there was some evidence for improved clinical outcome. Our results do not support that MUF improves postoperative organ function by modulation of the measured markers of inflammation.

Immunologic and Infectious Diseases in Pediatric Cardiac Critical Care: Proceedings of the 10th International Pediatric Cardiac Intensive Care Society Conference

Since the inception of the Pediatric Cardiac Intensive Care Society (PCICS) in 2003, remarkable advances in the care of children with critical cardiac disease have been developed. Specialized surgical approaches, anesthesiology practices, and intensive care management have all contributed to improved outcomes. However, significant morbidity often results from immunologic or infectious disease in the perioperative period or during a medical intensive care unit admission. The immunologic or infectious illness may lead to fever, which requires the attention and resources of the cardiac intensivist. Frequently, cardiopulmonary bypass leads to an inflammatory state that may present hemodynamic challenges or complicate postoperative care. However, inflammation unchecked by a compensatory anti-inflammatory response may also contribute to the development of capillary leak and lead to a complicated intensive care unit course. Any patient admitted to the intensive care unit is at risk for a hospital acquired infection, and no patients are at greater risk than the child treated with mechanical circulatory support. In summary, the prevention, diagnosis, and management of immunologic and infectious diseases in the pediatric cardiac intensive care unit is of paramount importance for the clinician. This review from the tenth PCICS International Conference will summarize the current knowledge in this important aspect of our field.

Oxidative Stress after Surgery on the Immature Heart

Paediatric heart surgery is associated with increased inflammation and the production of reactive oxygen species. Use of the extracorporeal cardiopulmonary bypass during correction of congenital heart defects generates reactive oxygen species by various mechanisms: haemolysis, neutrophil activation, ischaemia reperfusion injury, reoxygenation injury, or depletion of the endogenous antioxidants. The immature myocardium is more vulnerable to reactive oxygen species because of developmental differences compared to the adult heart but also because of associated congenital heart diseases that can deplete its antioxidant reserve. Oxidative stress can be manipulated by various interventions: exogenous antioxidants, use of steroids, cardioplegia, blood prime strategies, or miniaturisation of the cardiopulmonary bypass circuit. However, it is unclear if modulation of the redox pathways can alter clinical outcomes. Further studies powered to look at clinical outcomes are needed to define the role of oxidative stress in paediatric patients.

Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Hormone Replacement Therapy

OBJECTIVE

To provide an overview of the current literature on the use of hormone replacement therapies in pediatric cardiac critical care.

DATA SOURCES

PubMed, EMBASE, and the Cochrane Library were searched using keywords relevant to the hormonal therapy, with no limits on language but restricting the search to children 0-18 years old.

STUDY SELECTION

All clinical studies believed to have relevance were considered. Where studies in children were sparse, additional evidence was sought from adult studies.

DATA EXTRACTION

All relevant studies were reviewed, and the most relevant data were incorporated in this review.

DATA SYNTHESIS

All authors of this review contributed to the appraisal of the data extracted. Challenges and revisions by the authors were conducted by group e-mail debate.

CONCLUSIONS

Glycemic control: although it is likely that some children could benefit, the routine use of tight glycemic control cannot be recommended in children after cardiac surgery. Thyroid hormone replacement: routine use of thyroid hormone replacement to normalize levels after cardiac surgery cannot be recommended on current evidence. Until further evidence from adequately powered studies is available, therapeutic decisions should be based on individual patient circumstances. Corticosteroids: 1) cardiopulmonary bypass: although studies seem to favor steroid administration during surgery with cardiopulmonary bypass, a large randomized controlled trial is required before strong recommendations can be made; 2) refractory hypotension: the evidence for the use of steroid replacement in refractory hypotension is poor, and no firm recommendations can be made; and 3) abnormal adrenal function after cardiac surgery: there is inadequate evidence on which to make recommendations on the use of corticosteroid replacement in children with critical illness-related corticosteroid insufficiency in children following cardiac surgery.