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Yan Y, Kamenshchikov N, Zheng Z, Lei C. Inhaled nitric oxide and postoperative outcomes in cardiac surgery with cardiopulmonary bypass: A systematic review and meta-analysis. Nitric Oxide 2024; 146:64-74. [PMID: 38556145 DOI: 10.1016/j.niox.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
Cardiac surgeries under cardiopulmonary bypass (CPB) are complex procedures with high incidence of complications, morbidity and mortality. The inhaled nitric oxide (iNO) has been frequently used as an important composite of perioperative management during cardiac surgery under CPB. We conducted a meta-analysis of published randomized clinical trials (RCTs) to assess the effects of iNO on reducing postoperative complications, including the duration of postoperative mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay, mortality, hemodynamic improvement (the composite right ventricular failure, low cardiac output syndrome, pulmonary arterial pressure, and vasoactive inotropic score) and myocardial injury biomarker (postoperative troponin I levels). Subgroup analyses were performed to assess the effect of modification and interaction. These included iNO dosage, the timing and duration of iNO therapy, different populations (children and adults), and comparators (other vasodilators and placebo or standard care). A comprehensive search for iNO and cardiac surgery was performed on online databases. Twenty-seven studies were included after removing the duplicates and irrelevant articles. The results suggested that iNO could reduce the duration of mechanical ventilation, but had no significance in the ICU stay, hospital stay, and mortality. This may be attributed to the small sample size of the most included studies and heterogeneity in timing, dosage and duration of iNO administration. Well-designed, large-scale, multicenter clinical trials are needed to further explore the effect of iNO in improving postoperative prognosis in cardiovascular surgical patients.
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Affiliation(s)
- Yun Yan
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China; Department of Anesthesiology, China-Japan Friendship Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100029, China
| | - Nikolay Kamenshchikov
- Laboratory of Critical Care Medicine, Department of Anesthesiology and Intensive Care, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk, 634012, Russian Federation
| | - Ziyu Zheng
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China.
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Mozun R, Schlapbach LJ. A Critique of the "Conservative Versus Liberal Oxygenation Targets in Critically Ill Children" Multicenter, Randomized Clinical Trial Published in the Lancet 2024-More on "Less Is More?". Pediatr Crit Care Med 2024:00130478-990000000-00330. [PMID: 38602435 DOI: 10.1097/pcc.0000000000003519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Rebeca Mozun
- Department of Intensive Care and Neonatology, Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
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Brock MA, Ebraheem M, Jaudon A, Narasimhulu SS, Vazquez-Colon Z, Philip J, Lopez-Colon D, Jacobs JP, Bleiweis MS, Peek GJ. The safe addition of nitric oxide to the sweep gas of the extracorporeal membrane oxygenation circuit in a pediatric cardiac intensive care unit. Perfusion 2024:2676591241246079. [PMID: 38581646 DOI: 10.1177/02676591241246079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2024]
Abstract
Background: Nitric Oxide (NO) is a naturally occurring modulator of inflammation found in the human body. Several studies in the pediatric cardiothoracic surgery literature have demonstrated some beneficial clinical effects when NO is added to the sweep gas of the cardiopulmonary bypass circuit.Purpose: Our primary aim was to determine the safety of incorporating nitric oxide into the oxygenator sweep gas of the extracorporeal membrane oxygenation (ECMO) circuit. Secondarily, we looked at important clinical outcomes, such as survival, blood product utilization, and common complications related to ECMO.Methods: We performed a single center, retrospective review of all patients at our institution who received ECMO between January 1, 2017 and March 31, 2023. We began additing NO to the ECMO sweep gas in 2019. Results: There were no instances of clinically significant methemoglobinemia with the addition of NO to the sweep gas (0% vs 0%, p = 1). The median daily methemoglobin level was higher in those who received NO via the sweep gas when compared to those who did not (1.6 vs 1.1, p = <0.001). Conclusions: The addition of NO to the sweep gas of the ECMO circuit is safe.
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Affiliation(s)
- Michael A Brock
- Department of Pediatrics, Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | - Mohammed Ebraheem
- Department of Pediatrics, Division of Cardiology, Stanford University, Palo Alto, CA, USA
| | - Andrew Jaudon
- Department of Respiratory Care, ECMO coordinator, UF Health Shands Teaching Hospital, Gainvesville, FL, USA
| | | | - Zasha Vazquez-Colon
- Department of Pediatrics, Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | - Joseph Philip
- Department of Pediatrics, Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | - Dalia Lopez-Colon
- Department of Pediatrics, Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | - Jeffrey P Jacobs
- Department of Pediatrics, Congenital Heart Center, University of Florida, Gainesville, FL, USA
- Department of Surgery, Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | - Mark S Bleiweis
- Department of Pediatrics, Congenital Heart Center, University of Florida, Gainesville, FL, USA
- Department of Surgery, Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | - Giles J Peek
- Department of Pediatrics, Congenital Heart Center, University of Florida, Gainesville, FL, USA
- Department of Surgery, Congenital Heart Center, University of Florida, Gainesville, FL, USA
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Le Marsney R, Johnson K, Chumbes Flores J, Coetzer S, Darvas J, Delzoppo C, Jolly A, Masterson K, Sherring C, Thomson H, Ergetu E, Gilholm P, Gibbons KS. Assessing the impact of risk-based data monitoring on outcomes for a paediatric multicentre randomised controlled trial. Clin Trials 2024:17407745231222019. [PMID: 38420923 DOI: 10.1177/17407745231222019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND/AIMS Regulatory guidelines recommend that sponsors develop a risk-based approach to monitoring clinical trials. However, there is a lack of evidence to guide the effective implementation of monitoring activities encompassed in this approach. The aim of this study was to assess the efficiency and impact of the risk-based monitoring approach used for a multicentre randomised controlled trial comparing treatments in paediatric patients undergoing cardiac bypass surgery. METHODS This is a secondary analysis of data from a randomised controlled trial that implemented targeted source data verification as part of the risk-based monitoring approach. Monitoring duration and source to database error rates were calculated across the monitored trial dataset. The monitored and unmonitored trial dataset, and simulated trial datasets with differing degrees of source data verification and cohort sizes were compared for their effect on trial outcomes. RESULTS In total, 106,749 critical data points across 1,282 participants were verified from source data either remotely or on-site during the trial. The total time spent monitoring was 365 hours, with a median (interquartile range) of 10 (7, 16) minutes per participant. An overall source to database error rate of 3.1% was found, and this did not differ between treatment groups. A low rate of error was found for all outcomes undergoing 100% source data verification, with the exception of two secondary outcomes with error rates >10%. Minimal variation in trial outcomes were found between the unmonitored and monitored datasets. Reduced degrees of source data verification and reduced cohort sizes assessed using simulated trial datasets had minimal impact on trial outcomes. CONCLUSIONS Targeted source data verification of data critical to trial outcomes, which carried with it a substantial time investment, did not have an impact on study outcomes in this trial. This evaluation of the cost-effectiveness of targeted source data verification contributes to the evidence-base regarding the context where reduced emphasis should be placed on source data verification as the foremost monitoring activity.
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Affiliation(s)
- Renate Le Marsney
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
| | - Kerry Johnson
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | | | - Shelley Coetzer
- Paediatric Intensive Care Unit, Starship Child Health, Auckland, New Zealand
| | - Jennifer Darvas
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Carmel Delzoppo
- Paediatric Intensive Care Unit, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Arielle Jolly
- Paediatric Intensive Care Unit, Perth Children's Hospital, Perth, WA, Australia
| | - Kate Masterson
- Paediatric Intensive Care Unit, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Claire Sherring
- Paediatric Intensive Care Unit, Starship Child Health, Auckland, New Zealand
| | - Hannah Thomson
- Paediatric Intensive Care Unit, Perth Children's Hospital, Perth, WA, Australia
| | - Endrias Ergetu
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
| | - Patricia Gilholm
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
| | - Kristen S Gibbons
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
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Brinkley L, Brock MA, Stinson G, Bilgili A, Jacobs JP, Bleiweis M, Peek GJ. The biological role and future therapeutic uses of nitric oxide in extracorporeal membrane oxygenation, a narrative review. Perfusion 2024:2676591241228169. [PMID: 38226651 DOI: 10.1177/02676591241228169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
BACKGROUND Nitric oxide (NO) is a gas naturally produced by the human body that plays an important physiological role. Specifically, it binds guanylyl cyclase to induce smooth muscle relaxation. NO's other protective functions have been well documented, particularly its protective endothelial functions, effects on decreasing pulmonary vascular resistance, antiplatelet, and anticoagulation properties. The use of nitric oxide donors as vasodilators has been known since 1876. Inhaled nitric oxide has been used as a pulmonary vasodilator and to improve ventilation perfusion matching since the 1990s. It is currently approved by the United States Food and Drug Administration for neonates with hypoxic respiratory failure, however, it is used off-label for acute respiratory distress syndrome, acute bronchiolitis, and COVID-19. PURPOSE In this article we review the currently understood biological action and therapeutic uses of NO through nitric oxide donors such as inhaled nitric oxide. We will then explore recent studies describing use of NO in cardiopulmonary bypass and extracorporeal membrane oxygenation and speculate on NO's future uses.
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Greenberg JW, Hogue S, Raees MA, Ahmed HF, Abplanalp WA, Guzman-Gomez A, Abdelhamed Z, Thangappan K, Reagor JA, Rose JE, Collins M, Kasten JL, Goldstein SL, Zafar F, Morales DLS, Cooper DS. Exogenous nitric oxide delivery protects against cardiopulmonary bypass-associated acute kidney injury: Histologic and serologic evidence from an ovine model. J Thorac Cardiovasc Surg 2023; 166:e164-e173. [PMID: 37164051 DOI: 10.1016/j.jtcvs.2023.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Several human studies have associated nitric oxide administration via the cardiopulmonary bypass circuit with decreased incidence of cardiopulmonary bypass-associated acute kidney injury, but histopathologic and serologic evidence of nitric oxide efficacy for acute kidney injury attenuation are lacking. METHODS By using a survival ovine model (72 hours), acute kidney injury was induced by implementing low-flow cardiopulmonary bypass for 2 hours, followed by full-flow cardiopulmonary bypass for 2 hours. The nitric oxide cohort (n = 6) received exogenous nitric oxide through the cardiopulmonary bypass circuit via the oxygenator, and the control group (n = 5) received no nitric oxide. Serial serologic biomarkers and renal histopathology were obtained. RESULTS Baseline characteristics (age, weight) and intraoperative parameters (cardiopulmonary bypass time, urine output, heart rate, arterial pH, and lactate) were equivalent (P > .10) between groups. Postoperatively, urine output, heart rate, respiratory rate, and peripheral arterial saturation were equivalent (P > .10) between groups. Post-cardiopulmonary bypass creatinine elevations from baseline were significantly greater in the control group versus the nitric oxide group at 16, 24, and 48 hours (all P < .05). Histopathologic evidence of moderate/severe acute kidney injury (epithelial necrosis, tubular slough, cast formation, glomerular edema) occurred in 60% (3/5) of the control group versus 0% (0/6) of the nitric oxide group. Cortical tubular epithelial cilia lengthening (a sensitive sign of cellular injury) was significantly greater in the control group than in the nitric oxide group (P = .012). CONCLUSIONS In a survival ovine cardiopulmonary bypass model, nitric oxide administered with cardiopulmonary bypass demonstrated serologic and histologic evidence of renal protection from acute kidney injury. These results provide insight into 1 potential mechanism for cardiopulmonary bypass-associated acute kidney injury and supports continued study of nitric oxide via cardiopulmonary bypass circuit for prevention of acute kidney injury.
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Affiliation(s)
- Jason W Greenberg
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Spencer Hogue
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Muhammad Aanish Raees
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Hosam F Ahmed
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - William A Abplanalp
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amalia Guzman-Gomez
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Zakia Abdelhamed
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Karthik Thangappan
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James A Reagor
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James E Rose
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michaela Collins
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jennifer L Kasten
- Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stuart L Goldstein
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Clark JB. Commentary: Encouraging findings for the renal-protective effect of nitric oxide administration during cardiopulmonary bypass. J Thorac Cardiovasc Surg 2023; 166:e176-e177. [PMID: 37164057 DOI: 10.1016/j.jtcvs.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Joseph B Clark
- Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pa.
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Abouzid M, Roshdy Y, Daniel JM, Rzk FM, Ismeal AAA, Hendawy M, Tanashat M, Elnagar M, Daoud N, Ramadan A. The beneficial use of nitric oxide during cardiopulmonary bypass on postoperative outcomes in children and adult patients: a systematic review and meta-analysis of 2897 patients. Eur J Clin Pharmacol 2023; 79:1425-1442. [PMID: 37650923 PMCID: PMC10618325 DOI: 10.1007/s00228-023-03554-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/13/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Investigate inhaled nitric oxide's influence on mortality rates, mechanical ventilation and cardiopulmonary bypass duration, and length of stay in the intensive care unit and hospital when administered during cardiopulmonary bypass. METHODS Following the PRISMA guidelines, we searched four electronic databases (PubMed, EMBASE, Cochrane Library, and Web of Science) up to 4th March 2023. The protocol was registered in the PROSPERO database with ID: CRD42023423007. Using Review Manager software, we reported outcomes as risk ratios (RRs) or mean difference (MD) and confidence intervals (CIs). RESULTS The meta-analysis included a total of 17 studies with 2897 patients. Overall, there were no significant differences in using nitric oxide over control concerning mortality (RR = 1.03, 95% CI 0.73 to 1.45; P = 0.88) or cardiopulmonary bypass duration (MD = -0.14, 95% CI - 0.96 to 0.69; P = 0.74). The intensive care unit days were significantly lower in the nitric oxide group than control (MD = -0.80, 95% CI - 1.31 to -0.29; P = 0.002). Difference results were obtained in terms of the length of stay in the hospital according to sensitivity analysis (without sensitivity [MD = -0.41, 95% CI - 0.79 to -0.02; P = 0.04] vs. with sensitivity [MD = -0.31, 95% CI - 0.69 to 0.07; P = 0.11]. Subgroup analysis shows that, in children, nitric oxide was favored over control in significantly reducing the duration of mechanical ventilation (MD = -4.58, 95% CI - 5.63 to -3.53; P < 0.001). CONCLUSION Using inhaled nitric oxide during cardiopulmonary bypass reduces the length of stay in the intensive care unit, and for children, it reduces the duration of mechanical ventilation.
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Affiliation(s)
- Mohamed Abouzid
- Department of Physical Pharmacy and Pharmacokinetics, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3 St., 60-806, Poznan, Poland.
- Doctoral School, Poznan University of Medical Sciences, 60-812, Poznan, Poland.
| | - Yara Roshdy
- Faculty of Medicine, South Valley University, Qena, Egypt
| | | | | | | | - Mohamed Hendawy
- Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
| | | | | | - Nada Daoud
- Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | - Alaa Ramadan
- Faculty of Medicine, South Valley University, Qena, Egypt
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Schlapbach LJ, Gibbons KS, Butt W, Kannankeril PJ, Li JS, Hill KD. Improving Outcomes for Infants After Cardiopulmonary Bypass Surgery for Congenital Heart Disease: A Commentary on Recent Randomized Controlled Trials. Pediatr Crit Care Med 2023; 24:961-965. [PMID: 37607086 PMCID: PMC10840795 DOI: 10.1097/pcc.0000000000003344] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
The recent NITRIC and STRESS trials demonstrate opportunities to perform pragmatic large randomized trials in congenital heart disease. We discuss lessons learnt from these trials which can inform future trial design and conduct in the field of pediatric heart surgery.
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Affiliation(s)
- Luregn J Schlapbach
- Child Health Research Centre, University of Queensland, Brisbane, QL, Australia
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kristen S Gibbons
- Child Health Research Centre, University of Queensland, Brisbane, QL, Australia
| | - Warwick Butt
- Intensive Care Unit, Royal Children's Hospital, Melbourne, VC, Australia
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VC, Australia
| | - Prince J Kannankeril
- Department of Pediatrics, Center for Pediatric Precision Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Jennifer S Li
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, NC
| | - Kevin D Hill
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, NC
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Radovskiy AM, Bautin AE, Marichev AO, Osovskikh VV, Semenova NY, Artyukhina ZE, Murashova LA, Zinserling VA. NO Addition during Gas Oxygenation Reduces Liver and Kidney Injury during Prolonged Cardiopulmonary Bypass. Pathophysiology 2023; 30:484-504. [PMID: 37873857 PMCID: PMC10594502 DOI: 10.3390/pathophysiology30040037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/25/2023] Open
Abstract
Objective. To evaluate the effect of NO added to the sweep gas of the oxygenator during cardiopulmonary bypass (CPB) on the liver and kidneys in pigs. Methods. An experiment was carried out on 10 pigs undergoing cardiac surgery using CPB. NO was added to the sweep gas of the oxygenator at a concentration of 100 ppm for the animals in the experimental group (CPB-NO, n = 5). Animals in the control group (CPB-contr, n = 5) did not receive NO in the sweep gas of the oxygenator. The CPB lasted 4 h, followed by postoperative monitoring for 12 h. To assess the injury to the liver and kidneys, the levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, creatinine, and neutrophil gelatinase-associated lipocalin (NGAL) were determined initially, at weaning from the CPB, and 6 and 12 h after weaning from the CPB. The glomerular filtration rate (GFR) was evaluated initially, at weaning from the CPB, and 6 and 12 h after weaning from the CPB. A pathomorphological study of the liver and kidneys was performed using semiquantitative morphometry. Results. The long four-hour period of CPB deliberately used in our experiment caused liver and kidney injury. In the CPB-contr group, an increase in the ALT concentration was found: 43 (34; 44) U/L at baseline to 82 (53; 99) U/L 12 h after CPB, p < 0.05. The AST concentration in the CPB-contr group increased from 25 (17; 26) U/L at baseline to 269 (164; 376) U/L 12 h after CPB, p < 0.05. We found no significant increase in the ALT and AST concentrations in the CPB-NO group. There were no significant differences in ALT and AST concentrations between the CPB-NO and CPB-contr groups at all the study time-points. In the CPB-contr group, an increase in the creatinine level was found from 131 (129; 133) µmol/L at baseline to 273 (241; 306) µmol/L 12 h after CPB, p < 0.05. We found no significant increase in creatinine level in the CPB-NO group. Creatinine levels in the CPB-NO group were significantly lower than in the CPB-contr group 12 h after weaning from CPB: 183 (168; 196) vs. 273 (241; 306) µmol/L; p = 0.008. The GFR in the CPB-NO group was significantly higher than in the CPB-contr group 6 h after weaning from CPB: 78.9 (77.8; 82.3) vs. 67.9 (62.3; 69.2) mL/min; p = 0.016. GFR was significantly higher in the CPB-NO group than in the CPB-contr group 12 h after weaning from CPB: 67.7 (65.5; 68.0) vs. 50.3 (48.7; 54.9) mL/min; p = 0.032. We found no significant differences between the study groups in the level of NGAL. We found several differences between the groups in the pathomorphological study. Conclusions. NO added to the sweep gas of the oxygenator reduces creatinine levels and increases GFR during prolonged CPB injury. Further research is required.
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Long D, Anderson VA, Crossley L, Sood NT, Charles KR, MacDonald AD, Bora S, Pestell CF, Murrell K, Pride NA, Anderson PJ, Badawi N, Rose B, Baillie H, Masterson K, Chumbes Flores J, Sherring C, Raman S, Beca J, Erickson S, Festa M, Anderson BW, Venugopal P, Yim D, Andrews D, Cheung M, Brizard C, Gentles TL, Iyengar A, Nicholson I, Ayer J, Butt W, Schlapbach LJ, Gibbons KS. Longitudinal cohort study investigating neurodevelopmental and socioemotional outcomes in school-entry aged children after open heart surgery in Australia and New Zealand: the NITRIC follow-up study protocol. BMJ Open 2023; 13:e075429. [PMID: 37648380 PMCID: PMC10471882 DOI: 10.1136/bmjopen-2023-075429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/09/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Despite growing awareness of neurodevelopmental impairments in children with congenital heart disease (CHD), there is a lack of large, longitudinal, population-based cohorts. Little is known about the contemporary neurodevelopmental profile and the emergence of specific impairments in children with CHD entering school. The performance of standardised screening tools to predict neurodevelopmental outcomes at school age in this high-risk population remains poorly understood. The NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) trial randomised 1371 children <2 years of age, investigating the effect of gaseous nitric oxide applied into the cardiopulmonary bypass oxygenator during heart surgery. The NITRIC follow-up study will follow this cohort annually until 5 years of age to assess outcomes related to cognition and socioemotional behaviour at school entry, identify risk factors for adverse outcomes and evaluate the performance of screening tools. METHODS AND ANALYSIS Approximately 1150 children from the NITRIC trial across five sites in Australia and New Zealand will be eligible. Follow-up assessments will occur in two stages: (1) annual online screening of global neurodevelopment, socioemotional and executive functioning, health-related quality of life and parenting stress at ages 2-5 years; and (2) face-to-face assessment at age 5 years assessing intellectual ability, attention, memory and processing speed; fine motor skills; language and communication; and socioemotional outcomes. Cognitive and socioemotional outcomes and trajectories of neurodevelopment will be described and demographic, clinical, genetic and environmental predictors of these outcomes will be explored. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Children's Health Queensland (HREC/20/QCHQ/70626) and New Zealand Health and Disability (21/NTA/83) Research Ethics Committees. The findings will inform the development of clinical decision tools and improve preventative and intervention strategies in children with CHD. Dissemination of the outcomes of the study is expected via publications in peer-reviewed journals, presentation at conferences, via social media, podcast presentations and medical education resources, and through CHD family partners. TRIAL REGISTRATION NUMBER The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry as 'Gene Expression to Predict Long-Term Neurodevelopmental Outcome in Infants from the NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC) Study - A Multicentre Prospective Trial'. TRIAL REGISTRATION ACTRN12621000904875.
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Affiliation(s)
- Debbie Long
- School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Vicki A Anderson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Psychology Service, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Louise Crossley
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Nikita Tuli Sood
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Karina R Charles
- School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Anna D MacDonald
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - Samudragupta Bora
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Mater Research Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Carmela F Pestell
- School of Psychological Science, University of Western Australia, Crawley, Western Australia, Australia
| | - Kathryn Murrell
- Consult Liaison Team, Starship Children's Hospital, Auckland, New Zealand
| | - Natalie A Pride
- Kids Neuroscience Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Peter J Anderson
- Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
| | - Nadia Badawi
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Brian Rose
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Australian and New Zealand Fontan Advocacy Committee, HeartKids Australia Inc, Sydney, New South Wales, Australia
| | - Heidi Baillie
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Kate Masterson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Jenipher Chumbes Flores
- Paediatric Intensive Care Unit, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Claire Sherring
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
| | - Sainath Raman
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - John Beca
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand
| | - Simon Erickson
- Paediatric Intensive Care Unit, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Marino Festa
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Benjamin W Anderson
- Queensland Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, South Brisbane, Queensland, Australia
| | - Prem Venugopal
- School of Medicine, The University of Queensland, South Brisbane, Queensland, Australia
- Department of Cardiac Surgery, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Deane Yim
- Department of Paediatric Cardiology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - David Andrews
- Department of Cardiothoracic Surgery, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Michael Cheung
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Cardiology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Christian Brizard
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Cardiac Surgery, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Thomas L Gentles
- Paediatrics, Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Ajay Iyengar
- Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Ian Nicholson
- Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Julian Ayer
- Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Warwick Butt
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
- Department of Intensive Care and Neonatology, University Children's Hospital Zürich, Zürich, Switzerland
| | - Kristen S Gibbons
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
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12
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Xu F, Li W. Delivery exogenous nitric oxide via cardiopulmonary bypass in pediatric cardiac surgery reduces the duration of postoperative mechanical ventilation-A meta-analysis of randomized controlled trials. Heliyon 2023; 9:e19007. [PMID: 37636442 PMCID: PMC10447988 DOI: 10.1016/j.heliyon.2023.e19007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/21/2023] [Accepted: 08/04/2023] [Indexed: 08/29/2023] Open
Abstract
Objectives Cardiopulmonary bypass (CPB) is a major part of cardiac surgery that provokes systemic inflammatory reactions, myocardial ischemia, and ischemia and reperfusion damage. The aim of this study is to summarize the available evidence and evaluate whether exogenous nitric oxide administered via CPB circuits can improve recovery after cardiac surgery in children. Method A comprehensive search of the PubMed Medline, Ovid, Cochrane Library and Embase databases was conducted in September 2022. Only randomized controlled trials that compared nitro oxide with placebo or standard care were included. Results This pooled analysis included 5 RCTs containing 1642 patients. There were significant differences in the duration of postoperative mechanical ventilation between the nitric oxide group and the control group (mean difference -5.645 h; 95% CL = -9.978, -1.313; P = 0.01). Meta-analysis of the length of ICU stay and hospital stay showed no significant differences. Conclusion Delivering nitric oxide via CPB in pediatric cardiac surgery has an effect on reducing the duration of mechanical ventilation. Considering the small effect size, we should be cautious and think comprehensively in clinical practice.
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Affiliation(s)
- Fei Xu
- Corresponding author. Department of Anesthesiology, Chengdu Women's and Children's Central Hospital, Chengdu, 610031, Sichuan, China.
| | - Weina Li
- Department of Anesthesiology, Chengdu Women's and Children's Central Hospital, Chengdu, 610031, Sichuan, China
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13
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Bierer J, Stanzel R, Henderson M, Sett S, Sapp J, Andreou P, Marshall JS, Horne D. Novel inflammatory mediator profile observed during pediatric heart surgery with cardiopulmonary bypass and continuous ultrafiltration. J Transl Med 2023; 21:439. [PMID: 37408044 DOI: 10.1186/s12967-023-04255-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/09/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) is associated with systemic inflammation, featuring increased levels of circulating pro-inflammatory cytokines. Intra-operative ultrafiltration extracts fluid and inflammatory factors potentially dampening inflammation-related organ dysfunction and enhancing post-operative recovery. This study aimed to define the impact of continuous subzero-balance ultrafiltration (SBUF) on circulating levels of major inflammatory mediators. METHODS Twenty pediatric patients undergoing cardiac surgery, CPB and SBUF were prospectively enrolled. Blood samples were collected prior to CPB initiation (Pre-CPB Plasma) and immediately before weaning off CPB (End-CPB Plasma). Ultrafiltrate effluent samples were also collected at the End-CPB time-point (End-CPB Effluent). The concentrations of thirty-nine inflammatory factors were assessed and sieving coefficients were calculated. RESULTS A profound increase in inflammatory cytokines and activated complement products were noted in plasma following CBP. Twenty-two inflammatory mediators were detected in the ultrafiltrate effluent. Novel mediators removed by ultrafiltration included cytokines IL1-Ra, IL-2, IL-12, IL-17A, IL-33, TRAIL, GM-CSF, ET-1, and the chemokines CCL2, CCL3, CCL4, CXCL1, CXCL2 and CXCL10. Mediator extraction by SBUF was significantly associated with molecular mass < 66 kDa (Chi2 statistic = 18.8, Chi2 with Yates' correction = 16.0, p < 0.0001). There was a moderate negative linear correlation between molecular mass and sieving coefficient (Spearman R = - 0.45 and p = 0.02). Notably, the anti-inflammatory cytokine IL-10 was not efficiently extracted by SBUF. CONCLUSIONS CPB is associated with a burden of circulating inflammatory mediators, and SBUF selectively extracts twenty of these pro-inflammatory factors while preserving the key anti-inflammatory regulator IL-10. Ultrafiltration could potentially function as an immunomodulatory therapy during pediatric cardiac surgery. Trial registration ClinicalTrials.gov, NCT05154864. Registered retrospectively on December 13, 2021. https://clinicaltrials.gov/ct2/show/record/NCT05154864 .
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Affiliation(s)
- Joel Bierer
- Division of Cardiac Surgery, Dalhousie University, Halifax, Canada.
| | - Roger Stanzel
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Canada
| | - Mark Henderson
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Canada
| | - Suvro Sett
- Division of Cardiac Surgery, Dalhousie University, Halifax, Canada
| | - John Sapp
- Division of Cardiology, Dalhousie University, Halifax, Canada
| | - Pantelis Andreou
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Canada
| | - Jean S Marshall
- Department of Microbiology & Immunology, Dalhousie University, Halifax, Canada
| | - David Horne
- Division of Cardiac Surgery, Dalhousie University, Halifax, Canada
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14
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Gilholm P, Gibbons K, Brüningk S, Klatt J, Vaithianathan R, Long D, Millar J, Tomaszewski W, Schlapbach LJ. Machine learning to predict poor school performance in paediatric survivors of intensive care: a population-based cohort study. Intensive Care Med 2023; 49:785-795. [PMID: 37354231 PMCID: PMC10354166 DOI: 10.1007/s00134-023-07137-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/09/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE Whilst survival in paediatric critical care has improved, clinicians lack tools capable of predicting long-term outcomes. We developed a machine learning model to predict poor school outcomes in children surviving intensive care unit (ICU). METHODS Population-based study of children < 16 years requiring ICU admission in Queensland, Australia, between 1997 and 2019. Failure to meet the National Minimum Standard (NMS) in the National Assessment Program-Literacy and Numeracy (NAPLAN) assessment during primary and secondary school was the primary outcome. Routine ICU information was used to train machine learning classifiers. Models were trained, validated and tested using stratified nested cross-validation. RESULTS 13,957 childhood ICU survivors with 37,200 corresponding NAPLAN tests after a median follow-up duration of 6 years were included. 14.7%, 17%, 15.6% and 16.6% failed to meet NMS in school grades 3, 5, 7 and 9. The model demonstrated an Area Under the Receiver Operating Characteristic curve (AUROC) of 0.8 (standard deviation SD, 0.01), with 51% specificity to reach 85% sensitivity [relative Area Under the Precision Recall Curve (rel-AUPRC) 3.42, SD 0.06]. Socio-economic status, illness severity, and neurological, congenital, and genetic disorders contributed most to the predictions. In children with no comorbidities admitted between 2009 and 2019, the model achieved a AUROC of 0.77 (SD 0.03) and a rel-AUPRC of 3.31 (SD 0.42). CONCLUSIONS A machine learning model using data available at time of ICU discharge predicted failure to meet minimum educational requirements at school age. Implementation of this prediction tool could assist in prioritizing patients for follow-up and targeting of rehabilitative measures.
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Affiliation(s)
- Patricia Gilholm
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Sarah Brüningk
- Department of Biosystems Science and Engineering, ETH Zurich, 4058, Basel, Switzerland
- SIB Swiss Institute of Bioinformatics, 1015, Lausanne, Switzerland
| | - Juliane Klatt
- Department of Biosystems Science and Engineering, ETH Zurich, 4058, Basel, Switzerland
- SIB Swiss Institute of Bioinformatics, 1015, Lausanne, Switzerland
| | - Rhema Vaithianathan
- Institute for Social Science Research, The University of Queensland, Brisbane, QLD, Australia
| | - Debbie Long
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Johnny Millar
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), ANZICS House, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Wojtek Tomaszewski
- Institute for Social Science Research, The University of Queensland, Brisbane, QLD, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.
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15
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Christensen E, Morabito J, Kowalsky M, Tsai JP, Rooke D, Clendenen N. Year in Review 2022: Noteworthy Literature in Cardiac Anesthesiology. Semin Cardiothorac Vasc Anesth 2023; 27:123-135. [PMID: 37126462 PMCID: PMC10445401 DOI: 10.1177/10892532231173074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Last year researchers made substantial progress in work relevant to the practice of cardiac anesthesiology. We reviewed 389 articles published in 2022 focused on topics related to clinical practice to identify 16 that will impact the current and future practice of cardiac anesthesiology. We identified 4 broad themes including risk prediction, postoperative outcomes, clinical practice, and technological advances. These articles are representative of the best work in our field in 2022.
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Affiliation(s)
- Elijah Christensen
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA
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16
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Kamenshchikov NO, Duong N, Berra L. Nitric Oxide in Cardiac Surgery: A Review Article. Biomedicines 2023; 11:biomedicines11041085. [PMID: 37189703 DOI: 10.3390/biomedicines11041085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/26/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
Perioperative organ injury remains a medical, social and economic problem in cardiac surgery. Patients with postoperative organ dysfunction have increases in morbidity, length of stay, long-term mortality, treatment costs and rehabilitation time. Currently, there are no pharmaceutical technologies or non-pharmacological interventions that can mitigate the continuum of multiple organ dysfunction and improve the outcomes of cardiac surgery. It is essential to identify agents that trigger or mediate an organ-protective phenotype during cardiac surgery. The authors highlight nitric oxide (NO) ability to act as an agent for perioperative protection of organs and tissues, especially in the heart-kidney axis. NO has been delivered in clinical practice at an acceptable cost, and the side effects of its use are known, predictable, reversible and relatively rare. This review presents basic data, physiological research and literature on the clinical application of NO in cardiac surgery. Results support the use of NO as a safe and promising approach in perioperative patient management. Further clinical research is required to define the role of NO as an adjunct therapy that can improve outcomes in cardiac surgery. Clinicians also have to identify cohorts of responders for perioperative NO therapy and the optimal modes for this technology.
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Affiliation(s)
- Nikolay O Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 634012 Tomsk, Russia
| | - Nicolette Duong
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA
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Stein ML, Bilal MB, Faraoni D, Zabala L, Matisoff A, Mossad EB, Mittnacht AJC, Nasr VG. Selected 2022 Highlights in Congenital Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00201-X. [PMID: 37085385 DOI: 10.1053/j.jvca.2023.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 04/23/2023]
Abstract
This article is a review of the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist, and was published in 2022. After a search of the United States National Library of Medicine PubMed database, several topics emerged in which significant contributions were made in 2022. The authors of this manuscript considered the following topics noteworthy to be included in this review-intensive care unit admission after congenital cardiac catheterization interventions, antifibrinolytics in pediatric cardiac surgery, the current status of the pediatric cardiac anesthesia workforce in the United States, and kidney injury and renal protection during congenital heart surgery.
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Affiliation(s)
- Mary L Stein
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Musa B Bilal
- Department of Anesthesiology, Perioperative and Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - David Faraoni
- Department of Anesthesiology, Perioperative and Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Luis Zabala
- Department of Anesthesia and Pain Medicine, UT Southwestern School of Medicine, Children's Medical Center Dallas, Dallas, TX
| | - Andrew Matisoff
- Department of Anesthesiology, Perioperative and Pain Medicine, George Washington University, Children's National Hospital, Washington, DC
| | - Emad B Mossad
- Department of Anesthesiology, Perioperative and Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alexander J C Mittnacht
- Department of Anesthesiology, New York Medical College, Westchester Medical Center, Valhalla, NY.
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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18
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Mattke AC, Johnson K, Gibbons K, Long D, Robertson J, Venugopal PS, Blumenthal A, Schibler A, Schlapbach L. Nitric Oxide on Extracorporeal Membrane Oxygenation in Neonates and Children (NECTAR Trial): Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e43760. [PMID: 36920455 PMCID: PMC10131908 DOI: 10.2196/43760] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/11/2023] [Accepted: 01/28/2023] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) provides support for the pulmonary or cardiovascular function of children in whom the predicted mortality risk remains very high. The inevitable host inflammatory response and activation of the coagulation cascade due to the extracorporeal circuit contribute to additional morbidity and mortality in these patients. Mixing nitric oxide (NO) into the sweep gas of ECMO circuits may reduce the inflammatory and coagulation cascade activation during ECMO support. OBJECTIVE The purpose of this study is to test the feasibility and safety of mixing NO into the sweep gas of ECMO systems and assess its effect on inflammation and coagulation system activation through a pilot randomized controlled trial. METHODS The Nitric Oxide on Extracorporeal Membrane Oxygenation in Neonates and Children (NECTAR) trial is an open-label, parallel-group, pilot randomized controlled trial to be conducted at a single center. Fifty patients who require ECMO support will be randomly assigned to receive either NO mixed into the sweep gas of the ECMO system at 20 ppm for the duration of ECMO or standard care (no NO) in a 1:1 ratio, with stratification by support type (veno-venous vs veno-arterial ECMO). RESULTS Outcome measures will focus on feasibility (recruitment rate and consent rate, and successful inflammatory marker measurements), the safety of the intervention (oxygenation and carbon dioxide control within defined parameters and methemoglobin levels), and proxy markers of efficacy (assessment of cytokines, chemokines, and coagulation factors to assess the impact of NO on host inflammation and coagulation cascade activation, clotting of ECMO components, including computer tomography scanning of oxygenators for clot assessments), bleeding complications, as well as total blood product use. Survival without ECMO and the length of stay in the pediatric intensive care unit (PICU) are clinically relevant efficacy outcomes. Long-term outcomes include neurodevelopmental assessments (Ages and Stages Questionnaire, Strength and Difficulties Questionnaire, and others) and quality of life (Pediatric Quality of Life Inventory and others) measured at 6 and 12 months post ECMO cannulation. Analyses will be conducted on an intention-to-treat basis. CONCLUSIONS The NECTAR study investigates the safety and feasibility of NO as a drug intervention during extracorporeal life support and explores its efficacy. The study will investigate whether morbidity and mortality in patients treated with ECMO can be improved with NO. The intervention targets adverse outcomes in patients who are supported by ECMO and who have high expected mortality and morbidity. The study will be one of the largest randomized controlled trials performed among pediatric patients supported by ECMO. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12619001518156; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376869. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/43760.
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Affiliation(s)
- Adrian C Mattke
- Paediatric Intensive Care Unit, Children's Health Queensland, Queensland Children's Hospital, South Brisbane, Australia.,School of Medicine, University of Queensland, Herston, Australia.,Child Health Research Centre, The University of Queensland, South Brisbane, Australia
| | - Kerry Johnson
- Paediatric Intensive Care Unit, Children's Health Queensland, Queensland Children's Hospital, South Brisbane, Australia.,Child Health Research Centre, The University of Queensland, South Brisbane, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
| | - Debbie Long
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia
| | - Jeremy Robertson
- Paediatric Haematology and Haemophilia Service, Queensland Children's Hospital, South Brisbane, Australia
| | - Prem S Venugopal
- School of Medicine, University of Queensland, Herston, Australia.,Department for Cardiac Surgery, Queensland Children's Hospital, Children's Health Queensland, South Brisbane, Australia
| | - Antje Blumenthal
- Frazer Institute, The University of Queensland, Brisbane, Australia
| | | | - Luregn Schlapbach
- School of Medicine, University of Queensland, Herston, Australia.,University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
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