Effects of on-Table Extubation after Pediatric Cardiac Surgery

Background: Enhanced recovery after surgery (ERAS) protocols are utilizing a multidisciplinary approach, reassessing physiology to improve clinical outcomes, reducing length of hospital stay (LOS) stay, resulting in cost reduction. Since its introduction in colorectal surgery. the concept has been utilized in various fields and benefits have been recognized also in adult cardiac surgery. However, ERAS concepts in pediatric cardiac surgery are not yet widely established. Therefore, the aim of the present study was to assess the effects of on-table extubation (OTE) after pediatric cardiac surgery compared to the standard approach of delayed extubation (DET) during intensive care treatment. Study Design and Methods: We performed a retrospective analysis of all pediatric cardiac surgery cases performed in children below the age of two years using cardiopulmonary bypass at our institution in 2021. Exclusion criteria were emergency and off pump surgeries as well as children already ventilated preoperatively. Results: OTE children were older (267.3 days vs. 126.7 days, p < 0.001), had a higher body weight (7.0 ± 1.6 kg vs. 4.9 ± 1.9 kg, p < 0.001), showed significantly reduced duration of ICU treatment (75.9 ± 56.8 h vs. 217.2 ± 211.4 h, p < 0.001) and LOS (11.1 ± 10.2 days vs. 20.1 ± 23.4 days; p = 0.001) compared to DET group. Furthermore, OTE children had significantly fewer catecholamine dependencies at 12-, 24-, 48-, and 72-h post-surgery, while DET children showed a significantly increased intrafluid shift relative to body weight (109.1 ± 82.0 mL/kg body weight vs. 63.0 ± 63.0 mL/kg body weight, p < 0.001). After propensity score matching considering age, weight, bypass duration, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality (STATS)-Score, and the outcome variables, including duration of ICU treatment, catecholamine dependencies, and hospital LOS, findings significantly favored the OTE group. Conclusion: Our results suggest that on-table extubation after pediatric cardiac surgery is feasible and in our cohort was associated with a favorable postoperative course.

A Standardized Multimodal Neurological Monitoring Protocol-Guided Cerebral Protection Therapy for Venoarterial Extracorporeal Membrane Oxygenation Supported Patients

Background

The main objective of this study was to investigate the role of a multimodal neurological monitoring (MNM)-guided protocol in the precision identification of neural impairment and long-term neurological outcomes in venoarterial extracorporeal membrane oxygenation (VA-ECMO) supported patients.

Methods

We performed a cohort study that examined adult patients who underwent VA-ECMO support in our center between February 2010 and April 2021. These patients were retrospectively assigned to the “with MNM group” and the “without MNM group” based on the presence or absence of MNM-guided precision management. The differences in ECMO-related characteristics, evaluation indicators (precision, sensitivity, and specificity) of the MNM-guided protocol, and the long-term outcomes of the surviving patients were measured and compared between the two groups.

Results

A total of 63 patients with VA-ECMO support were retrospectively assigned to the without MNM group (n = 35) and the with MNM group (n = 28). The incidence of neural impairment in the without MNM group was significantly higher than that in the with MNM group (82.1 vs. 54.3%, P = 0.020). The MNM group exhibited older median ages [52.5 (39.5, 65.3) vs. 31 (26.5, 48.0), P = 0.008], a higher success rate of ECMO weaning (92.8 vs. 71.4%, P = 0.047), and a lower median duration of building ECMO [40.0 (35.0, 52.0) vs. 58.0 (48.0, 76.0), P = 0.025] and median ECMO duration days [5.0 (4.0, 6.2) vs. 7.0 (5.0, 10.5), P = 0.018] than the group without MNM. The MNM-guided protocol exhibited a higher precision rate (82.1 vs. 60.0%), sensitivity (95.7 vs. 78.9%), and specificity (83.3 vs. 37.5%) in identifying neural impairment in VA-ECMO support patients. There were significant differences in the long-term outcomes of survivors at 1, 3 and 6 months after discharge between the two groups (P < 0.05). However, the results showed no significant differences in ICU length of stay (LOS), hospital LOS, survival to discharge, or 28-day mortality between the two groups (P > 0.05).

Conclusion

The MNM-guided protocol is conducive to guiding intensivists in the improvement of cerebral protection therapy for ECMO-supported patients to detect and treat potential neurologic impairment promptly, and then improving long-term neurological outcomes after discharge.

[Monitoring of gastrointestinal dysfunction by near-infrared spectroscopy in children with sepsis: a prospective study]

OBJECTIVES

To investigate the incidence and mortality of gastrointestinal dysfunction in children with sepsis, the application of near-infrared spectroscopy (NIRS) in monitoring mesenteric regional tissue oxygen saturation (rSO₂), and the association between rSO₂ and gastrointestinal dysfunction.

METHODS

In this prospective study, 79 children with sepsis in the pediatric intensive care unit (sepsis group) and 40 children who underwent physical examination in the Department of Child Healthcare (healthy control group) from January to December, 2021 were enrolled as subjects. The related medical data were collected, including general information on admission and at discharge, treatment during hospitalization, and laboratory examination results. NIRS was used to measure mesenteric rSO₂. Clinical characteristics were compared between the patients with and without gastrointestinal dysfunction.

RESULTS

For the 79 children with sepsis, the incidence rate of gastrointestinal dysfunction was 49% (39/79), and the mortality rate of the children with gastrointestinal dysfunction was 26% (10/39). The children with gastrointestinal dysfunction had a longer duration of mechanical ventilation and a higher 28-day mortality rate (P<0.05). The children with gastrointestinal dysfunction had a significantly lower median rSO₂ (64%) than the children without gastrointestinal dysfunction (72%) and the healthy control group (78%) (P<0.05).

CONCLUSIONS

There are high incidence and mortality rates of gastrointestinal dysfunction in children with sepsis, and the reduction in rSO₂ may be associated with the development of gastrointestinal dysfunction.

Severe COVID-19 acute respiratory distress syndrome in an adult with single-ventricle physiology: a case report

Background

COVID-19 can induce acute respiratory distress syndrome (ARDS). In patients with congenital heart disease, established treatment strategies are often limited due to their unique cardiovascular anatomy and passive pulmonary perfusion.

Case presentation

We report the first case of an adult with single-ventricle physiology and bidirectional cavopulmonary shunt who suffered from severe COVID-19 ARDS. Treatment strategies were successfully adopted, and pulmonary vascular resistance was reduced, both medically and through prone positioning, leading to a favorable outcome.

Conclusion

ARDS treatment strategies including ventilatory settings, prone positioning therapy and cannulation techniques for extracorporeal oxygenation must be adopted carefully considering the passive venous return in patients with single-ventricle physiology.

Hypoplastic left heart syndrome: from fetus to fontan

The care of children with hypoplastic left heart syndrome is constantly evolving. Prenatal diagnosis of hypoplastic left heart syndrome will aid in counselling of parents, and selected fetuses may be candidates for in utero intervention. Following birth, palliation can be undertaken through staged operations: Norwood (or hybrid) in the 1st week of life, superior cavopulmonary connection at 4-6 months of life, and finally total cavopulmonary connection (Fontan) at 2-4 years of age. Children with hypoplastic left heart syndrome are at risk of circulatory failure their entire life, and selected patients may undergo heart transplantation. In this review article, we summarise recent advances in the critical care management of patients with hypoplastic left heart syndrome as were discussed in a focused session at the 12th International Conference of the Paediatric Cardiac Intensive Care Society held on 9 December, 2016, in Miami Beach, Florida.