Frequency and Outcome of Acute Neurologic Complications after Congenital Heart Disease Surgery

Incidence of neurological complications following pediatric heart surgery and its association with neutrophil-to-lymphocyte ratio

Background and Aims

Due to increased rate of open-heart surgeries in children, postsurgical mortality and morbidities have increasingly gained attention. Neurological complications are some of the most important postsurgical events. However, the number of studies regarding postsurgical neurological complications seems to be inadequate. We aimed to study the incidence of neurological complications following cardiac surgery in the pediatric cardiac intensive care unit (ICU) of the children's medical center.

Methods

This cross-sectional study was conducted from March to September 2019. We included all of the children who underwent cardiac surgery and were admitted to ICU at CMC. We collected their demographic data, lab test results (white blood cell count, absolute neutrophile and lymphocyte counts) and calculated their Risk Adjustment for Congenital Heart Surgery (RACHS) score. We then documented neurological adverse events and investigated the associations between those events and the patients' data.

Results

Of the 267 studied patients, 14 developed neurological complications (5.2%); seven developed chorea (2.6%), four developed seizures (1.5%), and two developed both seizure and chorea (0.7%). One case developed subarachnoid hemorrhage (SAH). We observed that age (p = 0.000), weight (p = 0.000), and RACHS score (p = 0.006) were associated with the development of neurological complications. Additionally, we observed that "neutrophil to lymphocyte ratio" was not associated with the risk of postsurgical neurological complications.

Conclusion

Younger age, lower weight, and higher RACHS score were associated with neurological complications after operations. Given the importance of postsurgical neurological complications, further investigations should be carried out to cover this issue and discover preventive strategies for such morbidities.

Neurological complications after pediatric cardiac surgery

Background

The number of pediatric patients who survive open-heart surgery has increased in recent years and the complications seen in this patient group continue to decrease with each technological advance, including new surgical and neuroprotective techniques and the improvement in surgeons' experience with this patient population. However, neurological complications, which are the most feared and difficult to manage, require long-term follow-up, and increase hospital costs remain a leading cause of mortality and morbidity in this cohort.

Results

We evaluated the neurological physical examination, cranial computed tomography (CT), and magnetic resonance (MRI) records of 162 pediatric patients with neurological symptoms lasting more than 24 h after undergoing heart surgery in our clinic between June 2012 and May 2020. The patients' ages ranged from 0 to 205 months, with a mean of 60.59 ± 46.44 months.Of the 3849 pediatric cardiac surgery patients we screened, 162 had neurological complications in the early period (the first 10 days after surgery). The incidence was calculated as 4.2%; 69 patients (42.6%) experienced seizures, 17 (10.5%) experienced confusion, 39 (24.1%) had stupor, and 37 (22.8%) had hemiparesis. Of the patients who developed neurological complications, 54 (33.3%) died. Patients with neurological complications were divided into 3 groups: strokes (n = 90), intracranial bleeding (n = 37), and no radiological results (n = 35). Thirty-four patients (37.8%) in the stroke group died, as did 15 (40%) in the bleeding group, and 5 (14.3%) in the no radiological results group.

Conclusions

Studies on neurological complications after pediatric heart surgery in the literature are currently insufficient. We think that this study will contribute to a more detailed discussion of the issue. Responses to neurological events and treatment in the pediatric group may differ compared to the adult age group. Primary prevention methods should be the main approach in combating neurological complications; their formation mechanisms should be carefully monitored and preventive treatment strategies should be developed.

Efficacy and Safety of Antifibrinolytic Drugs in Pediatric Surgery: A Systematic Review

Antifibrinolytic drugs are used to reduce blood loss and subsequent transfusions during surgery and following trauma, but the optimal dosing regimen in the pediatric population is still unresolved. The aim of this systematic review was to evaluate efficacy and safety of antifibrinolytic drugs in pediatric surgery and trauma to determine the optimal dosing regimen. A literature search was performed in PubMed, Embase, Cochrane, and Web of Science on May 3, 2020. We included randomized controlled studies investigating the effect of tranexamic acid (TXA), aprotinin, and epsilon-aminocaproic acid, in terms of reducing blood loss, blood transfusions, reoperations, and rebleeds in pediatric patients aged 0 to 18 years undergoing cardiac surgery, noncardiac surgery, or trauma. Fifty randomized controlled trials (RCTs) were included; 28 RCTs investigated cardiac surgery and 22 investigated noncardiac surgery. No RCTs regarding trauma met the inclusion criteria. All antifibrinolytic drugs reduced postoperative blood loss and transfusions when used in pediatric surgery. The dosing regimen varied between studies, but similar effect sizes were found in terms of reduced blood loss regardless of the cumulative dose used. Few studies found adverse events, and no difference in incidence or type of adverse events was seen between the antifibrinolytic and the placebo group. In conclusion, use of antifibrinolytics is efficient and safe in children undergoing surgery. We propose TXA as the drug of choice based on its level of evidence and safety profile; we recommend a dosing regimen composed of a loading dose of 10 to 15 mg/kg prior to surgery followed by 1 to 5 mg/kg/h as continuous infusion throughout surgery.

Increased prevalence of inattention-related symptoms in a large cohort of patients with congenital heart disease

The objective of this study is to assess the prevalence and risk factors for attention-deficit hyperactivity disorder (ADHD) in a large cohort of patients with congenital heart disease (CHD). Patients (n = 695) with CHD who were aged 6-15 years and visited the outpatient clinics in our hospital from June 2015 to May 2017 were enrolled. Their medical records were collected, and the Chinese version of the Swanson, Nolan, and Pelham rating scale (SNAP-IVc) and a questionnaire about neuropsychiatric care-seeking behavior were completed by parents and counselors. Of the 695 patients, the overall prevalence of ADHD was 12.4%, including 3.2% for the combined subtype, 6.8% for the inattentive-predominant subtype, and 2.4% for the hyperactivity/impulsive-predominant subtype. Only the inattention-predominant subtype was significantly more prevalent than in the general population. The prevalence of the inattention-predominant subtype was highest in the patients with cyanotic CHD, high severity index, and in those who had received surgery or cardiopulmonary bypass. Multivariate regression analysis indicated that the risk factors for inattention-related symptoms included postoperative seizure and previous cardiopulmonary bypass (odds ratio: 3.22 and 3.82; P = 0.027 and < 0.001, respectively). Only 58.7% of the patients with probable ADHD ever sought neuropsychiatric care, and only 27% regularly attended neuropsychiatric clinics. The inattention-predominant subtype of ADHD was more prevalent in our CHD patients, especially in those with cyanotic CHD, higher disease severity index, and in those who had undergone a surgical intervention. The percentage of patients receiving regular neuropsychiatric clinic follow-up was low.

Cerebral oxygenation during pediatric congenital cardiac surgery and its association with outcome: a retrospective observational study

Purpose

Non-invasive cerebral oxygen saturation (ScO₂) monitoring is an established tool in the intraoperative phase of pediatric congenital cardiac surgery (CCS). This study investigated the association between ScO₂ and postoperative outcome by investigating both baseline ScO₂ values and intraoperative desaturations from baseline.

Methods

All CCS procedures performed in the period 2010-2017 in our institution in which ScO₂ was monitored were included in this historical cohort study. Baseline ScO₂ was determined after tracheal intubation, before surgical incision. Subgroups were based on cardiac pathology and degree of intracardiac shunting. Poor outcome was defined based on length of stay (LOS) in the intensive care unit (ICU)/hospital, duration of mechanical ventilation (MV), and 30-day mortality. Intraoperatively, ScO₂ total time below baseline (TBBL) and ScO₂ time-weighted average (TWA) were calculated.

Results

Data from 565 patients were analyzed. Baseline ScO₂ was significantly associated with LOS in ICU (odds ratio [OR] per percentage decrease in baseline ScO₂, 0.95; 95% confidence interval [CI], 0.93 to 0.97; P < 0.001), with LOS in hospital (OR, 0.93; 95% CI, 0.91 to 0.96; P < 0.001), with MV duration (OR, 0.92; 95% CI, 0.90 to 0.95; P < 0.001) and with 30-day mortality (OR, 0.94; 95% CI, 0.91 to 0.98; P = 0.007). Cerebral oxygen saturation TWA had no associations, while ScO₂ TBBL had only a small association with LOS in ICU (OR, 1.02; 95% CI, 1.01 to 1.03; P < 0.001), MV duration (OR,1.02; 95% CI, 1.01 to 1.03; P = 0.002), and LOS in hospital (OR, 1.02; 95% CI, 1.01 to 1.04; P < 0.001).

Conclusion

In pediatric patients undergoing cardiac surgery, low baseline ScO₂ values measured after tracheal intubation were associated with several adverse postoperative outcomes. In contrast, the severity of actual intraoperative cerebral desaturation was not associated with postoperative outcomes. Baseline ScO₂ measured after tracheal intubation may help identify patients at increased perioperative risk.