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Joshi RK, Joshi R, Aggarwal N, Agarwal M, Siddartha CR, Relan J, Kumar A, Modi M, Chug P. Comparison of Levosimendan Versus Milrinone After the Arterial Switch Operation for Infants ≤3 kg. World J Pediatr Congenit Heart Surg 2024:21501351241239306. [PMID: 38766718 DOI: 10.1177/21501351241239306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Background: Various inotropes and inodilators have been utilized to treat low cardiac output syndrome after the arterial switch operation. The use of levosimendan, a calcium sensitizer has been limited in this setting. This study compares the effects of levosimendan with milrinone in managing low cardiac output after the arterial switch operation. Methods: A retrospective, comparative study was conducted in a tertiary care hospital on patients weighing up to 3 kg undergoing the arterial switch operation between January 2017 and January 2022. Patients received a loading dose followed by continuous infusion of either levosimendan or milrinone. Echocardiographic, hemodynamic and biochemical parameters were compared. Results: Forty-three patients received levosimendan and 42 patients received milrinone as the primary test drug. Cardiac index of less than 2.2 L/min/m2 on postoperative day 1 and 2 was found in 9.3% and 2.3% of patients receiving levosimendan versus 26.2% and 11.9% in those receiving milrinone, respectively (P = .04 and .08, respectively). Early lactate-clearance and better central venous oxygen saturations were noted in the levosimendan group. Prevalence of acute kidney injury was higher in the milrinone group (50% vs 28%; P = .03). Use of peritoneal dialysis in the milrinone group versus levosimendan was 31% and 16.3%, respectively (P = .11). There was no difference in hospital mortality between the groups (milrinone, 3; levosimendan, 2, P = .62). Conclusions: Levosimendan is safe and as effective as milrinone to treat low cardiac output syndrome occurring in neonates after the arterial switch operation. In addition we found that levosimendan was renal protective when compared with milrinone.
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Affiliation(s)
- Reena Khantwal Joshi
- Division of Pediatric Cardiac Anesthesia, Sir Ganga Ram Hospital, New Delhi, India
| | - Raja Joshi
- Division of Pediatric Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Neeraj Aggarwal
- Division of Pediatric Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Mridul Agarwal
- Division of Pediatric Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Jay Relan
- Division of Pediatric Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil Kumar
- Division of Pediatric Cardiac Intensive Care, Sir Ganga Ram Hospital, New Delhi, India
| | - Manoj Modi
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Parul Chug
- Department of Biotechnology & Research, Sir Ganga Ram Hospital, New Delhi, India
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Matsushita FY, Krebs VLJ, De Carvalho WB. Association between Serum Lactate and Morbidity and Mortality in Neonates: A Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1796. [PMID: 38002887 PMCID: PMC10670916 DOI: 10.3390/children10111796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE Lactate is a marker of hypoperfusion in critically ill patients. Whether lactate is useful for identifying and stratifying neonates with a higher risk of adverse outcomes remains unknown. This study aimed to investigate the association between lactate and morbidity and mortality in neonates. METHODS A meta-analysis was performed to determine the association between blood lactate levels and outcomes in neonates. Ovid MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov were searched from inception to 1 May 2021. A total of 49 observational studies and 14 data accuracy test studies were included. The risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies and the QUADAS-2 tool for data accuracy test studies. The primary outcome was mortality, while the secondary outcomes included acute kidney injury, necessity for renal replacement therapy, neurological outcomes, respiratory morbidities, hemodynamic instability, and retinopathy of prematurity. RESULTS Of the 3184 articles screened, 63 studies fulfilled all eligibility criteria, comprising 46,069 neonates. Higher lactate levels are associated with mortality (standard mean difference, -1.09 [95% CI, -1.46 to -0.73]). Using the estimated sensitivity (0.769) and specificity (0.791) and assuming a prevalence of 15% for adverse outcomes (median of prevalence among studies) in a hypothetical cohort of 10,000 neonates, assessing the lactate level alone would miss 346 (3.46%) cases (false negative) and wrongly diagnose 1776 (17.76%) cases (false positive). CONCLUSIONS Higher lactate levels are associated with a greater risk of mortality and morbidities in neonates. However, our results do not support the use of lactate as a screening test to identify adverse outcomes in newborns. Research efforts should focus on analyzing serial lactate measurements, rather than a single measurement.
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Affiliation(s)
- Felipe Yu Matsushita
- Department of Pediatrics, Neonatology Division, Faculty of Medicine, University of São Paulo, São Paulo 01246-903, Brazil; (V.L.J.K.); (W.B.D.C.)
- Instituto da Criança, Av. Dr. Enéas de Carvalho Aguiar, 647, São Paulo 05403-000, Brazil
| | - Vera Lucia Jornada Krebs
- Department of Pediatrics, Neonatology Division, Faculty of Medicine, University of São Paulo, São Paulo 01246-903, Brazil; (V.L.J.K.); (W.B.D.C.)
- Instituto da Criança, Av. Dr. Enéas de Carvalho Aguiar, 647, São Paulo 05403-000, Brazil
| | - Werther Brunow De Carvalho
- Department of Pediatrics, Neonatology Division, Faculty of Medicine, University of São Paulo, São Paulo 01246-903, Brazil; (V.L.J.K.); (W.B.D.C.)
- Instituto da Criança, Av. Dr. Enéas de Carvalho Aguiar, 647, São Paulo 05403-000, Brazil
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Iacobelli R, Ricci Z, Marinari E, Haiberger R, Di Molfetta A, Toscano A, Di Chiara L. Effects of levosimendan on ventriculo-arterial coupling and cardiac efficiency in paediatric patients with single-ventricle physiology after surgical palliation: retrospective study. Interact Cardiovasc Thorac Surg 2020; 30:623-629. [PMID: 31986196 DOI: 10.1093/icvts/ivz319] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
The use of levosimendan for paediatric patients with low cardiac output after congenital heart surgery has been recently described. We sought to evaluate ventriculo-arterial coupling (VAC) and other ventricular energetic parameters before and after 72 h from levosimendan start in infants with single-ventricle physiology and cardiac failure after palliation with Norwood or hybrid procedures.
METHODS
In this single-centre retrospective study, 9 consecutive patients affected by hypoplastic left heart syndrome-like anatomy were retrospectively analysed. Systolic elastance, diastolic elastance, arterial elastance, VAC and cardiac mechanical efficiency were calculated by measuring, through 2-dimensional echocardiography, end-systolic volume and end-diastolic volume and by recording mean arterial pressure and central venous pressure.
RESULTS
The median (range) weight and age were 2.8 (2.3–6) kg and 16.5 (6–116) days, respectively. After 72 h from levosimendan start, end-systolic volume significantly decreased (−1 ml, −3.2 to −0.1, P = 0.007), whereas mean arterial pressure and end-diastolic volume remained stable. Heart rate showed a significant decrease (−28 beats/min, −41 to 22, P = 0.008). Systolic elastance (2.9 mmHg/ml, 0.4–5.4, P = 0.008), arterial elastance (−5.9, −24 to −0.5, P = 0.038), VAC (−0.86, −1.5 to −0.16, P = 0.009) and cardiac mechanical efficiency (0.18, 0.03–0.22, P = 0.008) differences also showed significant modifications.
CONCLUSIONS
In a small case series of patients with single-ventricle physiology, levosimendan showed to improve contractility and optimize VAC, with a reduction of heart rate. Monitoring of VAC and ventricular energetics can be an interesting aspect to improve the management of heart failure in infants with univentricular anatomy.
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Affiliation(s)
- Roberta Iacobelli
- Pediatric Cardiology Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Zaccaria Ricci
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Eleonora Marinari
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Roberta Haiberger
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Arianna Di Molfetta
- Department of Cardiac Surgery, Policlinico Universitario A. Gemelli, Rome, Italy
| | - Alessandra Toscano
- Pediatric Cardiology Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Luca Di Chiara
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
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Suominen P, Mattila N, Nyblom O, Rautiainen P, Turanlahti M, Rahkonen O. The Hemodynamic Effects and Safety of Repetitive Levosimendan Infusions on Children With Dilated Cardiomyopathy. World J Pediatr Congenit Heart Surg 2016; 8:25-31. [PMID: 28033083 DOI: 10.1177/2150135116674466] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Limited treatment options are available for children with decompensated dilated cardiomyopathy (DCM), while they wait for either functional recovery or heart transplantation. We evaluated the safety of repetitive levosimendan infusions and short-term and long-term impacts of the therapy in this patient population. METHODS Eighty-one repetitive levosimendan infusions administered to 20 patients with DCM at severe or end stage of the disease in the pediatric intensive care unit were analyzed retrospectively. Echocardiographic assessments were reinterpreted by two experienced pediatric cardiologists. The mean follow-up time after therapy was 9.8 ± 3.3 years. RESULTS The median age of the patients at the time of the first levosimendan infusion was 1.1 years (interquartile range: 0.3-2.1). Transient hypotension was reported in 17.3% of the infusions. No significant changes in the mean ejection fraction were detected after repetitive levosimendan infusion (31.6 ± 12.5 vs 33.1 ± 12.4; P = .39) or for the laboratory parameters for the group as a whole. In 7 (35%) of 20 patients, the mean ejection fraction improved from 20% ± 12% to 35% ± 11% ( P = .003). The administration of concomitant medications and time may have contributed to the healing process of these patients. Two patients were removed from the transplantation waiting-list owing to clinical recovery after six months of therapy. The long-term survival rate was 70% (n = 14 of 20). CONCLUSIONS Repetitive levosimendan infusions in children with DCM appeared to be hemodynamically well tolerated without severe adverse events. Although one-third of the children had a good response to repetitive levosimendan infusions, no overall significant improvement in ventricular performance could be found in this heterogenous DCM patient population, which included the patients in end-stage heart failure.
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Affiliation(s)
- Pertti Suominen
- 1 Department of Anaesthesia and Intensive Care, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Niklas Mattila
- 1 Department of Anaesthesia and Intensive Care, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Olle Nyblom
- 2 Department of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Paula Rautiainen
- 1 Department of Anaesthesia and Intensive Care, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Maila Turanlahti
- 2 Department of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Otto Rahkonen
- 2 Department of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
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Séguéla PE, Tafer N, Thambo JB, Mauriat P. [Use of levosimendan in children]. Arch Pediatr 2016; 23:848-56. [PMID: 27369103 DOI: 10.1016/j.arcped.2016.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 03/09/2016] [Accepted: 05/10/2016] [Indexed: 11/17/2022]
Abstract
Levosimendan is a calcium-sensitizing drug with positive inotropic properties. As an inodilator, this molecule also has a vasodilation effect. While its efficacy has been demonstrated in the adult in the context of cardiac surgery, its pediatric use is still not widespread. Many studies have shown its safety of use in children, including in the newborn. Across the world, a growing number of teams use levosimendan to treat both acute and chronic heart failure. Through a review of the literature, we describe its pharmacodynamic effects, its current applications, and its perspectives of use in children.
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Affiliation(s)
- P-E Séguéla
- Service de cardiologie pédiatrique et congénitale, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac cedex, France; Service de réanimation chirurgicale des cardiopathies congénitales, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France.
| | - N Tafer
- Service de réanimation chirurgicale des cardiopathies congénitales, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France
| | - J-B Thambo
- Service de cardiologie pédiatrique et congénitale, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac cedex, France
| | - P Mauriat
- Service de réanimation chirurgicale des cardiopathies congénitales, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France
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Averin K, Villa C, Krawczeski CD, Pratt J, King E, Jefferies JL, Nelson DP, Cooper DS, Ryan TD, Sawyer J, Towbin JA, Lorts A. Initial Observations of the Effects of Calcium Chloride Infusions in Pediatric Patients with Low Cardiac Output. Pediatr Cardiol 2016; 37:610-7. [PMID: 26687150 DOI: 10.1007/s00246-015-1322-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
Abstract
Myocardial contractility and relaxation are highly dependent on calcium homeostasis. Immature myocardium, as in pediatric patients, is thought to be more dependent on extracellular calcium for optimal function. For this reason, intravenous calcium chloride infusions may improve myocardial function in the pediatric patient. The objectives of this study were to report the hemodynamic changes seen after administration of continuous calcium chloride to critically ill children. We retrospectively identified pediatric patients (newborn to 17 years old) with hemodynamic instability admitted to the cardiac ICU between May 2011 and May 2012 who received a continuous infusion of calcium chloride. The primary outcome was improvement in cardiac output, assessed by arterial-mixed venous oxygen saturation (A-V) difference. Sixty-eight patients, mean age 0.87 ± 2.67 years, received a total of 116 calcium infusions. Calcium chloride infusions resulted in significant improvements in primary and secondary measures of cardiac output at 2 and 6 h. Six hours after calcium initiation, A-V oxygen saturation difference decreased by 7.4 % (32.6 ± 2.1 to 25.2 ± 2.0 %, p < 0.001), rSO2 increased by 5.5 % (63.1 vs 68.6 %, p < 0.001), and serum lactate decreased by 0.9 mmol/l (3.3 vs 2.4 mmol/l, p < 0.001) with no change in HR (149.1 vs 145.6 bpm p = 0.07). Urine output increased 0.66 ml/kg/h in the 8-h period after calcium initiation when compared to pre-initiation (p = 0.003). Neonates had the strongest evidence of effectiveness with other age groups trending toward significance. Calcium chloride infusions improve markers of cardiac output in a heterogenous group of pediatric patients in a cardiac ICU. Neonates appear to derive the most benefit from utilization of these infusions.
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Affiliation(s)
- Konstantin Averin
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Chet Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Catherine D Krawczeski
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.,The Heart Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Jesse Pratt
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eileen King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John L Jefferies
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - David P Nelson
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Thomas D Ryan
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Jaclyn Sawyer
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeffrey A Towbin
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.,The Heart Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
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7
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Experience with levosimendan in 32 paediatric patients. Pediatr Cardiol 2015; 36:1038-41. [PMID: 25608697 DOI: 10.1007/s00246-015-1117-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 01/13/2015] [Indexed: 10/24/2022]
Abstract
The aim of this study was to describe the off-label conditions of use for levosimendan in the paediatric population of a tertiary referral hospital. This is a retrospective observational study conducted between January 2007 and January 2014. Inclusion criteria were as follows: 100 % of paediatric patients who received intravenous perfusions of levosimendan during the study period. The following data were gathered: age, sex, diagnosis, dose administered, duration and date of the perfusion, number of perfusions per patient, previous inotropic and concomitant treatment, side effects and survival. A total of 32 patients were included in the study (56 % male). The mean age at the moment of administration was 4 months (range 2 days-15 years). During the study period, a total of 70 infusions were recorded. Fifteen of the 32 patients (46.9 %) received repeat doses, with a mean interval between doses of 8 days (range 3-37 days). The doses used were between 0.05 and 0.2 mcg/kg/min. Loading doses were not used in any cases. At the moment of receiving the infusion, all of the patients were receiving conventional treatment without any response, including inotropic support in 88 % of the cases. The administration of levosimendan was only suspended in one case due to the appearance of severe hypotension. In the rest of the administrations, it was well tolerated, without registering any severe side effect during the infusion process. Levosimendan proved to be a safe, effective strategy in our paediatric population. The good tolerance observed may be related to the absence of an initial bolus or loading dose.
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Suominen PK. Single-center experience with levosimendan in children undergoing cardiac surgery and in children with decompensated heart failure. BMC Anesthesiol 2011; 11:18. [PMID: 21974814 PMCID: PMC3199236 DOI: 10.1186/1471-2253-11-18] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 10/05/2011] [Indexed: 12/02/2022] Open
Abstract
Background Levosimendan has pharmacologic and hemodynamic advantages over conventional intravenous inotropic agents. It has been used mainly as a rescue drug in the pediatric intensive care unit or in the operating room. We present the largest single-center experience of levosimendan in children. Methods Retrospective analysis of all children who received levosimendan infusions between July 5, 2001 and July 4, 2010 in a pediatric intensive care unit. The results of a questionnaire for physicians (anesthesiologist/intensivists, cardiologists and cardiac surgeons) concerning their clinical perceptions of levosimendan are evaluated Results During the study period a total of 484 infusions were delivered to 293 patients 53% of whom were male. The median age of the patients was 0.4 years (4 hours-21.1 years) at the time of levosimendan administration. A majority of levosimendan infusions were administered to children who were undergoing cardiac surgery (72%), 14% to children with cardiomyopathy and 14% to children with cardiac failure. Eighty-nine out of the 293 patients (30.4%) received repeated doses of levosimendan (up to 11 infusions). The most common indication for the use of levosimendan (94%) was when the other inotropic agents were insufficient to maintain stable hemodynamics. Levosimendan was especially used in children with cardiomyopathy (100%) or with low cardiac output syndrome (94%). A majority (89%) of the respondents believed that levosimendan administration postponed the need for mechanical assist devices in some children with cardiomyopathy. Moreover, 44% of respondents thought that the mechanical support was totally avoided in some patients undergoing cardiac surgery after receiving levosimendan. Conclusion Levosimendan is widely used in our institution and many physicians believe that its use could decrease the need for mechanical support in children undergoing cardiac surgery or in children with decompensated heart failure. However, there is a lack of good empirical evidence in children to support this perception.
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Affiliation(s)
- Pertti K Suominen
- Department of Anesthesia and Intensive Care, Children's Hospital, Helsinki University, Central Hospital, P,O B, 281 Stenbäckinkatu 11, FIN-00029 HUCS Helsinki, Finland.
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