Vasopressin in the pediatric cardiac intensive care unit: Myth or reality

Minimizing Acute Kidney Injury in Pediatric Cardiac Surgery: Incidence, Early Detection, and Preemptive Measures

Background Acute kidney injury (AKI) poses a significant challenge in pediatric cardiac surgery, having a profound impact on patient morbidity and mortality. This study aims to determine the incidence of AKI, explore novel biomarkers for early detection, assess potential risk factors along with preemptive strategies to minimize its incidence and compare the results with similar studies that did not use these interventions. Methods This prospective observational cohort study, conducted from October 2022 to June 2024 at a tertiary care center, involved 44 pediatric patients, aged three months to 15 years, undergoing cardiac surgery. Kidney function was assessed through preoperative and postoperative measurements of serum creatinine, urine output, blood urea, and newer biomarkers such as cystatin C and urine neutrophil gelatinase-associated lipocalin (NGAL). AKI was defined and classified using the Acute Kidney Injury Network (AKIN) criteria, based on increases in serum creatinine or reductions in urine output within the first three days post surgery. To reduce the risk of AKI, a low-dose vasopressin infusion and blood transfusion were administered to maintain renal perfusion and optimal hematocrit levels. The incidence of AKI was calculated and compared with other studies that did not utilize these strategies Results AKI occurred in 31.8% (n=14) of the pediatric patients undergoing cardiac surgery. To reduce the risk of AKI, preemptive low-dose vasopressin was used as a preventive strategy. Patients who developed AKI exhibited significant elevations in serum creatinine, blood urea, and cystatin C, with postoperative NGAL levels exceeding 50 ng/ml. The study found a strong correlation between lower intraoperative hematocrit levels (<30%) and a higher incidence of AKI (100% vs. 6.2%, p<0.001). Conclusions Effective management of intraoperative hematocrit levels and the preemptive use of vasopressin are promising strategies for reducing AKI risk by optimizing renal perfusion and function during cardiac surgery. Early detection through biomarkers like cystatin C and NGAL offers the potential for timely intervention and better patient outcomes. These findings contribute to improving risk assessment and perioperative management in pediatric patients vulnerable to AKI.

Pharmacogenomics of Pediatric Cardiac Arrest: Cisplatin Treatment Worsened by a Ryanodine Receptor 2 Gene Mutation

In thelast few decades, the roles of cardio-oncology and cardiovascular geneticsgained more and more attention in research and daily clinical practice, shaping a new clinical approach and management of patients affected by cancer and cardiovascular disease. Genetic characterization of patients undergoing cancer treatment can support a better cardiovascular risk stratification beyond the typical risk factors, suchas contractile function and QT interval duration, uncovering a possible patient’s concealed predisposition to heart failure, life threatening arrhythmias and sudden death. Specifically, an integrated cardiogenetic approach in daily oncological clinical practice can ensure the best patient-centered healthcare model, suggesting, also the adequate cardiac monitoring timing and alternative cancer treatments, reducing drug-related complications. We report the case of a 14-month-old girl affected by neuroblastoma, treated by cisplatin, complicated by cardiac arrest. We described the genetic characterization of a Ryanodine receptor 2 (RYR2) gene mutation and subsequent pharmacogenomic approach to better shape the cancer treatment.

International Survey on the Use of Arginine Vasopressin in the Postoperative Management of Single Ventricle Patients

Management of patients with single ventricle physiology after surgical palliation is challenging. Arginine vasopressin has gained popularity in recent years as a non-catecholamine vasoactive medication due to its unique properties. However, data regarding its use in the pediatric population is limited. Therefore, we designed a survey to explore whether and how clinicians use this medication in intensive care units for the postoperative management of single ventricle patients. This international survey aimed to assess usage, practices, and concepts related to arginine vasopressin in pediatric intensive care units worldwide. Directors of pediatric intensive care units who are members of the following international professional societies: European Society of Pediatric Neonatal Intensive Care, Association for European Pediatric and Congenital Cardiology, and Pediatric Cardiac Intensive Care Society were invited to participate in this survey. Of the 62 intensive care unit directors who responded, nearly half use arginine vasopressin in the postoperative management of neonatal single ventricle patients, and 90% also use the drug in subsequent surgical palliation. The primary indications are vasoplegia, hemodynamic instability, and refractory shock, although it is still considered a second-line medication. Conceptual benefits include improved hemodynamics and end-organ perfusion and decreased incidence of low cardiac output syndrome. Those practitioners who do not use arginine vasopressin cite lack of availability, fear of potential adverse effects, unclear indication for use, and lack of evidence suggesting improved outcomes. Both users and non-users described increased myocardial afterload and extreme vasoconstriction as potential disadvantages of the medication. Despite the lack of conclusive data demonstrating enhanced clinical outcomes, our study found arginine vasopressin is used widely in the care of infants and children with single ventricle physiology after the first stage and subsequent palliative surgeries. While many intensive care units use this medication, few had protocols, offering an area for further growth and development.