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Pollak U, Avniel-Aran A, Binshtok AM, Bar-Yosef O, Bronicki RA, Checchia PA, Finkelstein Y. Exploring the Possible Role of Cannabinoids in Managing Post-Cardiac Surgery Complications: A Narrative Review of Preclinical Evidence and a Call for Future Research Directions. J Cardiovasc Pharmacol 2024:00005344-990000000-00298. [PMID: 38498618 DOI: 10.1097/fjc.0000000000001560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Open-heart surgery with cardiopulmonary bypass (CPB) often leads to complications including pain, systemic inflammation, and organ damage. Traditionally managed with opioids, these pain relief methods bring potential long-term risks, prompting the exploration of alternative treatments. The legalization of cannabis in various regions has reignited interest in cannabinoids, such as CBD, known for their anti-inflammatory, analgesic, and neuroprotective properties. Historical and ongoing research acknowledges the endocannabinoid system's crucial role in managing physiological processes, suggesting cannabinoids could offer therapeutic benefits in post-surgical recovery. Specifically, CBD has shown promise in managing pain, moderating immune responses, and mitigating ischemia/reperfusion injury, underscoring its potential in postoperative care. However, the translation of these findings into clinical practice faces challenges, highlighting the need for extensive research to establish effective, safe cannabinoid-based therapies for patients undergoing open-heart surgery. This narrative review advocates for a balanced approach, considering both the therapeutic potential of cannabinoids and the complexities of their integration into clinical settings.
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Affiliation(s)
- Uri Pollak
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Adi Avniel-Aran
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alexander M Binshtok
- Department of Medical Neurobiology, Institute for Medical Research Israel-Canada, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- The Edmond and Lily Safra Center for Brain Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Omer Bar-Yosef
- Pediatric Neurology and Child Development, The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronald A Bronicki
- Department of Pediatrics, Critical Care Medicine and Cardiology, Baylor College of Medicine, Houston, TX, USA
- Pediatric Cardiovascular Intensive Care Unit, Texas Children's Hospital, Houston, TX, USA
| | - Paul A Checchia
- Department of Pediatrics, Critical Care Medicine and Cardiology, Baylor College of Medicine, Houston, TX, USA
- Pediatric Cardiovascular Intensive Care Unit, Texas Children's Hospital, Houston, TX, USA
| | - Yaron Finkelstein
- Faculty of Medicine, Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Faculty of Medicine, Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Keizman E, Abarbanel I, Salem Y, Mishaly D, Serraf AE, Pollak U. The Impact of Dominant Ventricular Morphology on the Early Postoperative Course After the Glenn Procedure. Pediatr Cardiol 2023; 44:1076-1082. [PMID: 36781464 DOI: 10.1007/s00246-023-03114-z] [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: 12/28/2022] [Accepted: 01/23/2023] [Indexed: 02/15/2023]
Abstract
The dominant ventricular morphology affects both the early and late outcomes of the Fontan procedure, but its impact on the patients' status immediately following the Glenn procedure is unknown. This study aims to evaluate the effect of the infants' dominant ventricular morphology on the immediate course after undergoing the Glenn procedure. This single-center, retrospective study included all patients who underwent the Glenn procedure between October 2003 and May 2016. The patients were divided into two groups according to their dominant ventricular morphology. Their postoperative records were reviewed and compared. Out of the 89 patients who underwent the Glenn procedure during the study period, 40 (44.9%) had dominant right ventricular morphology and 49 (55.1%) had left ventricular morphology. There were no significant group differences in baseline characteristics or operative data. The maximal postoperative vasoactive-inotropic score was significantly higher and the extent of ventricular dysfunction was significantly more severe in the dominant right ventricle group (P < 0.05). The length of hospitalization was slightly but not significantly longer in the hypoplastic LV group. It is concluded that patients with a dominant LV morphology had a superior ventricular function and required less inotropic support compared to that of a dominant RV morphology in the immediate postoperative course following the Glenn procedure. Survival was not affected by these differences. Further study to determine the pathophysiologic basis for these differences is warranted.
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Affiliation(s)
- Eitan Keizman
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel.
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel.
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Tel Hashomer, Israel.
| | - Inbar Abarbanel
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
| | - Yishai Salem
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Alain E Serraf
- Pediatric and Congenital Heart Center, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel
- The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Uri Pollak
- The Hebrew University Hadassah Medical School, Jerusalem, Israel
- Section of Pediatric Critical Care, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel
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Pollak U, Zemmour H, Shaked E, Magenheim J, Fridlich O, Korach A, Serraf AE, Mishaly D, Glaser B, Shemer R, Dor Y. Novel cfDNA Methylation Biomarkers Reveal Delayed Cardiac Cell Death after Open-heart Surgery. J Cardiovasc Transl Res 2023; 16:199-208. [PMID: 35978264 DOI: 10.1007/s12265-022-10295-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/19/2022] [Indexed: 10/15/2022]
Abstract
The use of cardiopulmonary bypass (CPB) is thought to cause delayed cardiac damage. DNA methylation-based liquid biopsies are novel biomarkers for monitoring acute cardiac cell death. We assessed cell-free DNA molecules as markers for cardiac damage after open-heart surgery. Novel cardiomyocyte-specific DNA methylation markers were applied to measure cardiac cfDNA in the plasma of 42 infants who underwent open-heart surgery. Cardiac cfDNA was elevated following surgery, reflecting direct surgery-related tissue damage, and declined thereafter in most patients. The concentration of cardiac cfDNA post-surgery correlated with the duration of CPB and aortic cross clamping. Strikingly, cardiac cfDNA at 6 h predicted duration of mechanical ventilation and maximal vasoactive-inotropic score better than did maximal troponin levels. Cardiac cfDNA reveals heart damage associated with CPB, and can be used to monitor cardiac cell death, to predict clinical outcome of surgery and to assess performance of cardioprotective interventions.
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Affiliation(s)
- Uri Pollak
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hai Zemmour
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel
| | - Elior Shaked
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel
| | - Judith Magenheim
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel
| | - Ori Fridlich
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel
| | - Amit Korach
- Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Thoracic Surgery, Hadassah University Medical Center, Jerusalem, Israel
| | - Alain E Serraf
- Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Benjamin Glaser
- Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel.,Endocrinology and Metabolism Service, Hadassah University Medical Center, Jerusalem, Israel
| | - Ruth Shemer
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel.
| | - Yuval Dor
- Department of Developmental Biology and Cancer Research, Institute for Medical Research Israel-Canada, the Hebrew University-Hadassah Medical School, 91120, Jerusalem, Israel.
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Brooks R, Fisher R, Glicksman C, Pollak U, Simanovsky N, Berkun Y. Multisystem inflammatory syndrome in children associated with COVID-19 presenting as cervical inflammation. Acta Paediatr 2022; 112:477-482. [PMID: 36495064 PMCID: PMC9877739 DOI: 10.1111/apa.16623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/27/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022]
Abstract
AIM The major clinical manifestations multisystem inflammatory syndrome in children (MIS-C) are fever, gastrointestinal and cardiac. The aim of this study was to describe MIS-C in a series of patients who presented primarily with cervical manifestations. METHODS We retrospectively reviewed medical records of all patients who met the Centers for Disease Control and Prevention and World Health Organization MIS-C diagnostic criteria treated at Hadassah-Hebrew University Medical Center between April 2020 and September 2021. RESULTS Of 37 children diagnosed with MIS-C (median age: 10.2 years, range 1.5-18 years, 20 male) five, 13.5% (median age: 14.4 years, range 9.2-17.5 years) presented with cervical symptoms mimicking neck infections. One was hospitalised with a working diagnosis of retropharyngeal abscess, and four with acute cervical lymphadenitis that did not respond to early antibiotic treatment. All developed full MIS-C phenotype. CONCLUSION MIS-C may present as cervical inflammation. An ill-appearing child with symptoms and/or signs of cervical inflammation should be evaluated for clinical and laboratory features of MIS-C, thereby facilitating prompt treatment of this potentially fatal disorder.
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Affiliation(s)
- Rebecca Brooks
- Department of PediatricsHadassah ‐ Hebrew University Medical CenterJerusalemIsrael,Pediatric Intensive Care UnitHadassah‐Hebrew University Medical CenterJerusalemIsrael,Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
| | - Ron Fisher
- Department of Otorhinolaryngology/Head & Neck SurgeryHadassah Hebrew University Medical CenterJerusalemIsrael
| | - Charlotte Glicksman
- Department of PediatricsHadassah ‐ Hebrew University Medical CenterJerusalemIsrael,Pediatric Intensive Care UnitHadassah‐Hebrew University Medical CenterJerusalemIsrael
| | - Uri Pollak
- Pediatric Intensive Care UnitHadassah‐Hebrew University Medical CenterJerusalemIsrael,Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
| | - Natalia Simanovsky
- Faculty of MedicineHebrew University of JerusalemJerusalemIsrael,Department of RadiologyHadassah‐Hebrew University Medical CenterJerusalemIsrael
| | - Yackov Berkun
- Department of PediatricsHadassah ‐ Hebrew University Medical CenterJerusalemIsrael,Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
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Pollak U, Abarbanel I, Salem Y, Serraf AE, Mishaly D. Dominant Ventricular Morphology and Early Postoperative Course After the Fontan Procedure. World J Pediatr Congenit Heart Surg 2022; 13:346-352. [PMID: 35446208 PMCID: PMC9024023 DOI: 10.1177/21501351221081246] [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] [Indexed: 11/16/2022]
Abstract
Background Single ventricle heart disease comprises a wide variety of critical heart defects that lead to the provision of systemic cardiac output by one dominant ventricle. It requires staged surgical palliation that culminates in Fontan circulation. Dominant ventricular morphology in single ventricle patients reportedly has an impact on postoperative morbidity and mortality with varying results. The objectives of this study were to examine the association between ventricular morphology and the early postoperative course after the Fontan procedure. Methods A retrospective cohort study in a tertiary referral pediatric medical center that included 98 consecutive patients who underwent Fontan procedure between October 2009 and May 2016. Postoperative outcomes were compared between patients with left ventricular morphology and those with right ventricular morphology (crude effect and regression analysis). Results Patients with right ventricular morphology had longer postoperative hospitalizations compared to patients with left ventricular morphology (26.5 days vs 18.2 days, respectively, P = .028), higher postoperative maximal vasoactive-inotropic scores (25.6 vs 12.4, P = .02), higher serum lactate levels (7.7 mmol/L vs 6.4 mmol/L, P = .03), higher proportions of ventilation throughout 24 h or more (16 patients [38%] vs 8 patients [14%], P = .009), higher proportions of ventricular dysfunction (12 patients [29%] vs 5 patients [9%], P = .0001), and lower blood oxygen saturation levels at discharge (87% vs 92%, P = .03). Conclusions The Fontan procedure in patients with right ventricular morphology is associated with longer postoperative hospitalization and worse early postoperative characteristics (ventricular dysfunction and atrioventricular valve regurgitation) as well as higher rates of early, transient signs of sub-optimal postoperative hemodynamics compared to those with left ventricular morphology.
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Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Cardiology, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Jerusalem, Israel.,58884The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Inbar Abarbanel
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Yishay Salem
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiology, Edmond J. Safra International Congenital Heart Center, 146925The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Alain E Serraf
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, 26744The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, 26744The Chaim Sheba Medical Center, Tel Hashomer, Israel
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6
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Pollak U, Feinstein Y, Mannarino CN, McBride ME, Mendonca M, Keizman E, Mishaly D, van Leeuwen G, Roeleveld PP, Koers L, Klugman D. The horizon of pediatric cardiac critical care. Front Pediatr 2022; 10:863868. [PMID: 36186624 PMCID: PMC9523119 DOI: 10.3389/fped.2022.863868] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
Pediatric Cardiac Critical Care (PCCC) is a challenging discipline where decisions require a high degree of preparation and clinical expertise. In the modern era, outcomes of neonates and children with congenital heart defects have dramatically improved, largely by transformative technologies and an expanding collection of pharmacotherapies. Exponential advances in science and technology are occurring at a breathtaking rate, and applying these advances to the PCCC patient is essential to further advancing the science and practice of the field. In this article, we identified and elaborate on seven key elements within the PCCC that will pave the way for the future.
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Affiliation(s)
- Uri Pollak
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel.,Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yael Feinstein
- Pediatric Intensive Care Unit, Soroka University Medical Center, Be'er Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Candace N Mannarino
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Mary E McBride
- Divisions of Cardiology and Critical Care Medicine, Departments of Pediatrics and Medical Education, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Malaika Mendonca
- Pediatric Intensive Care Unit, Children's Hospital, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Eitan Keizman
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | - Grace van Leeuwen
- Pediatric Cardiac Intensive Care Unit, Sidra Medicine, Ar-Rayyan, Qatar.,Department of Pediatrics, Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Peter P Roeleveld
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Lena Koers
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Darren Klugman
- Pediatrics Cardiac Critical Care Unit, Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Johns Hopkins Medicine, Baltimore, MD, United States
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Kanthimathinathan HK, Pollak U, Shekerdemian L. Paediatric intensive care challenges caused by indirect effects of the COVID-19 pandemic. Intensive Care Med 2021; 47:698-700. [PMID: 33904948 PMCID: PMC8076876 DOI: 10.1007/s00134-021-06400-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/01/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Uri Pollak
- Section of Paediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel.,The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Lara Shekerdemian
- Texas Children's Hospital, Houston, TX, USA. .,Baylor College of Medicine, Houston, TX, USA.
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Kassif Lerner R, Pollak U. The use of therapeutic plasma exchange for pediatric patients supported on extracorporeal membranous oxygenator therapy: A narrative review. Perfusion 2020; 37:113-122. [PMID: 33349141 DOI: 10.1177/0267659120974324] [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: 11/16/2022]
Abstract
Therapeutic plasma exchange in children is increasingly recognized as a life-saving treatment and is challenged by some technical considerations. As extracorporeal membrane oxygenation has been used for nearly half a century for refractory reversible respiratory and/or cardiac failure in both pediatric and adult populations, it may serve as an extracorporeal platform for therapeutic plasma exchange. It is most commonly described in patients with sepsis with multiple organ failure or thrombocytopenia associated multi organ failure. Additional pathophysiological processes of inflammatory and immunological storms might benefit from the combination of extracorporeal membrane oxygenation and plasma exchange. This is a nonmethodological review of English-language reports of therapeutic plasma exchange performed in patients supported by extracorporeal membrane oxygenation, both pediatric and adult, searching six databases, MEDLINE, Clinical Key, GOOGLE SCHOLAR, CINAHL, Cochrane library, and EMBASE.
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Affiliation(s)
- Reut Kassif Lerner
- Department of pediatric intensive care, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel.,Pediatric Cardiology, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel.,Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel.,The Hebrew University Hadassah Medical School, Jerusalem, Israel
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9
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Bronicki RA, Flores S, Loomba RS, Checchia PA, Pollak U, Villarreal EG, Nickerson P, Graham EM. Impact of Corticosteroids on Cardiopulmonary Bypass Induced Inflammation in Children: A Meta-Analysis. Ann Thorac Surg 2020; 112:1363-1370. [PMID: 33309732 DOI: 10.1016/j.athoracsur.2020.09.062] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 09/01/2020] [Accepted: 09/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Corticosteroids suppress the inflammatory response to cardiopulmonary bypass in children undergoing cardiac surgery. What is less clear is the impact of corticosteroids on the postoperative course. METHODS A systematic review and meta-analysis was made of prospective randomized blinded placebo-controlled trials of pediatric patients who received corticosteroids or saline placebo before surgery was performed. Ten studies met inclusion criteria for a total of 768 patients. In a prespecified subgroup analysis, studies that either were limited to The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery congenital heart surgery mortality categories 1 and 2 or excluded neonates were eliminated and a secondary analysis was conducted, which consisted of seven studies and 555 patients. RESULTS Corticosteroids were associated with a significant improvement in fluid balance at 24 and 36 hours after surgery, with a mean difference of -15.2 mL/kg (95% confidence interval, 25.3 to -5.1 mL/kg; P < .01) and -5.7 mL/kg (95% confidence interval, -9.8 to -1.6 mL/kg; P < .01), respectively. Corticosteroids had no impact on the incidence of infection or mortality. With the secondary analysis, corticosteroids were associated with a trend toward significance in shortening the duration of mechanical ventilation (mean difference -0.7 days; 95% confidence interval, -1.7 to 0.1; P = .08). CONCLUSIONS Corticosteroids were found to have a favorable impact on postoperative fluid balance and may be associated with shortening the duration of mechanical ventilation. Although corticosteroids had no impact on mortality, they may be beneficial particularly for neonates and patients undergoing highly complex surgery.
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Affiliation(s)
- Ronald A Bronicki
- Department of Pediatrics, Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - Saul Flores
- Department of Pediatrics, Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas.
| | - Rohit S Loomba
- Department of Pediatrics, Chicago Medical School, Section of Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Paul A Checchia
- Department of Pediatrics, Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - Uri Pollak
- Department of Pediatrics, Hebrew University-Hadassah Medical School, Hebrew University of Jerusalem, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Enrique G Villarreal
- Department of Pediatrics, Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas; Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, México
| | - Parker Nickerson
- Department of Pediatrics, Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - Eric M Graham
- Department of Pediatrics, Medical University of South Carolina, Section of Cardiology, Medical University of South Carolina, Charleston, South Carolina
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10
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Pollak U. Neonatal Sepsis and Extracorporeal Membrane Oxygenation Support: Pushing the Envelope. Isr Med Assoc J 2020; 22:255-257. [PMID: 32286031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Critical Care Unit, Pediatric Cardiology and Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Jerusalem, Israel
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11
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Lerner RK, Gruber N, Pollak U. Congenital Heart Disease and Thyroid Dysfunction: Combination, Association, and Implication. World J Pediatr Congenit Heart Surg 2020; 10:604-615. [PMID: 31496400 DOI: 10.1177/2150135119857704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 11/16/2022]
Abstract
BACKGROUND Patients with congenital heart disease have higher prevalence of thyroid dysfunction due to embryonic and genetic coexistence. Marked changes in cardiac function occur secondary to alternations in thyroid hormone levels. Cardiac catheterizations or cardiac surgeries with cardiopulmonary bypass can cause abnormalities in the circulating hormones, in the absence of primary thyroid disease. Therefore, monitoring of thyroid function should be routinely performed in children with congenital heart disease. Thyroid hormone supplementation has been postulated as a possible therapeutic option; however, the therapeutic decisions should be made based on individual circumstances, symptoms, and the severity of the thyroid dysfunction. OBJECTIVES To describe the correlation between congenital heart disease in children and thyroid dysfunction and the debate on monitoring, intervention, and treatment. METHODS PubMed, Clinical Key, and the Cochrane Library were searched using keywords relevant to congenital heart disease/surgery, cardiopulmonary bypass, thyroid hormones, sick euthyroid syndrome, and cardiac catheterization. Studies were limited to the English language and to children 0 to 18 years old. Studies in adults with important findings were reviewed as well. All clinical studies believed to have relevance were considered. All relevant studies were reviewed, and the most pertinent data were incorporated in this review. CONCLUSION There is lack of significant evidence concerning treatment for thyroid dysfunction in children with a congenital cardiac diagnosis. Adequately powered studies are needed before a uniform recommendation about treatment can be made.
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Affiliation(s)
- Reut Kassif Lerner
- Department of Pediatrics, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noah Gruber
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Endocrine and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel.,Pediatric Cardiology, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel.,Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel.,The Hebrew University Hadassah Medical School, Jerusalem, Israel
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12
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Pollak U. Heparin-induced thrombocytopenia complicating extracorporeal membrane oxygenation support: Review of the literature and alternative anticoagulants. J Thromb Haemost 2019; 17:1608-1622. [PMID: 31313454 DOI: 10.1111/jth.14575] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [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: 04/25/2019] [Revised: 06/25/2019] [Accepted: 07/11/2019] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening prothrombotic, immune-mediated complication of unfractionated heparin and low molecular weight heparin therapy. HIT is characterized by moderate thrombocytopenia 5-10 days after initial heparin exposure, detection of platelet-activating anti-platelet factor 4/heparin antibodies and an increased risk of venous and arterial thrombosis. Extracorporeal membrane oxygenation (ECMO) is a form of mechanical circulatory support used in critically ill patients with respiratory or cardiac failure. Systemic anticoagulation is used to alleviate the thrombotic complications that may occur when blood is exposed to artificial surfaces within the ECMO circuit. Therefore, when HIT complicates patients on ECMO support, it is associated with a high thrombotic morbidity and mortality. The risk for HIT correlates with the accumulative dosage of heparin exposure. In ECMO patients receiving continuous infusion of heparin for circuit patency, the risk for HIT is not neglected and must be thought of in the differential diagnosis of the appropriate clinical and laboratory circumstances. The following article reviews the current knowledge in HIT complicating ECMO patients and the alternative anticoagulation options in the presence of HIT.
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Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Jerusalem, Israel
- Pediatric Cardiology, Hadassah University Medical Center, Jerusalem, Israel
- Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Jerusalem, Israel
- The Hebrew University Hadassah Medical School, Jerusalem, Israel
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Pollak U, Bronicki RA, Achuff BJ, Checchia PA. Postoperative Pain Management in Pediatric Patients Undergoing Cardiac Surgery: Where Are We Heading? J Intensive Care Med 2019:885066619871432. [PMID: 31446831 DOI: 10.1177/0885066619871432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 12/22/2022]
Abstract
OBJECTIVES Adequate postoperative pain management is crucial in pediatric patients undergoing cardiac surgery because pain can lead to devastating short- and long-term consequences. This review discusses the limitations of current postoperative pain assessment and management in children after cardiac surgery, the obstacles to providing optimal treatment, and concepts to consider that may overcome these barriers. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS Effective pain management in infants and young children undergoing cardiac surgery continues to evolve with innovative methods of both assessment and therapy using newer drugs or novel routes of administration. Artificial intelligence- and machine learning-based pain assessment and patient-tailored management in both pain measurement and prevention are already being integrated into the routine of current practice.
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Affiliation(s)
- Uri Pollak
- 1 Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel
- 2 Pediatric Cardiology, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel
- 3 Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel
- 4 The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Ronald A Bronicki
- 5 Department of Pediatrics, Critical Care Medicine and Cardiology, Baylor College of Medicine, Houston, TX, USA
- 6 Pediatric Cardiovascular Intensive Care Unit, Texas Children's Hospital, Houston, TX, USA
| | - Barbara-Jo Achuff
- 5 Department of Pediatrics, Critical Care Medicine and Cardiology, Baylor College of Medicine, Houston, TX, USA
- 6 Pediatric Cardiovascular Intensive Care Unit, Texas Children's Hospital, Houston, TX, USA
| | - Paul A Checchia
- 5 Department of Pediatrics, Critical Care Medicine and Cardiology, Baylor College of Medicine, Houston, TX, USA
- 6 Pediatric Cardiovascular Intensive Care Unit, Texas Children's Hospital, Houston, TX, USA
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Pollak U, Ruderman T, Borik-Chiger S, Mishaly D, Serraf A, Vardi A. Transfusion-related acute hepatic injury following postoperative platelets administration in pediatric patients undergoing the Fontan procedure. CONGENIT HEART DIS 2019; 14:968-977. [PMID: 31343842 DOI: 10.1111/chd.12825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 03/02/2019] [Revised: 05/11/2019] [Accepted: 07/08/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The final common pathway of single ventricle patients is the Fontan procedure. Among the immediate postoperative complications is acute hepatic injury presented by marked elevation of liver enzymes (alanine transaminase [ALT] and aspartate transaminase [AST]). We aimed to determine the contribution of blood products transfusion to acute hepatic injury. DESIGN Single center retrospective cohort study. SETTING Pediatric Cardiac Intensive Care Unit at a tertiary medical center. PATIENTS Ninety-nine pediatric patients undergoing the Fontan procedure between January 2009 and December 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Out of the four types of blood products, transfusion of platelets was found to significantly affect postoperative levels of ALT and AST. Additional factors included postoperative administration of sodium bicarbonate, decreased flow through the Fontan canal and decreased urine output. Preoperative pulmonary artery pressure and pulmonary vascular resistance, cardiopulmonary bypass time, aortic cross-clamp time, amount of postoperative bleeding, and vasoactive-inotropic score did not influence liver enzymes levels CONCLUSIONS: In pediatric Fontan patients, platelets transfusions contribute to an acute hepatic injury. The relation between platelets and transfusion-related acute lung injury (TRALI) has been well described, but this is the first time it is being described in regard to acute hepatic injury (TRAHI). Changing platelet transfusion strategy could decrease morbidity in Fontan patients but further research is needed.
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Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Cardiology, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Jerusalem, Israel.,The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Tatyana Ruderman
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Borik-Chiger
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiology, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Alain Serraf
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Amir Vardi
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiac Intensive Care Unit, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Keizman E, Tejman-Yarden S, Mishali D, Levine S, Borik S, Pollak U, Katz U, Serraf AE. The Bilateral Bidirectional Glenn Operation as a Risk Factor Prior to Fontan Completion in Complex Congenital Heart Disease Patients. World J Pediatr Congenit Heart Surg 2019; 10:174-181. [DOI: 10.1177/2150135118819997] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: The Glenn procedure is generally performed as a second-stage palliative procedure toward the completion of Fontan circulation in patients with a functionally univentricular heart. Safe Fontan completion requires normal ventricular function, competent atrioventricular valves, normal pulmonary arteries anatomy, and low pulmonary vascular resistances (PVRs), which is merely an estimation that considers both lungs as a single unit. Clinical observations revealed that patients who previously underwent bilateral bidirectional cavopulmonary anastomosis (b-BCPA) had a stormier postoperative course in respect to other patients with previous unilateral BCPA (u-BCPA) postoperatively after Fontan completion. This retrospective study was designed to compare and analyze the outcomes of patients following Fontan completion with previous u-BCPA versus b-BCPA. Patients and Methods: A total of 98 patients were divided into two groups based on the presence or absence of bilateral superior vena cava (SVC). Group 1 included 80 patients with unilateral SVC, and group 2 included 18 patients with bilateral SVC. Univariate and multivariate (SPSS) analyses were performed with regard to mortality and failure. P value of <.05 was considered as significant. Results: Prior to the total cavopulmonary anastomosis operation, the G1 and G2 had similar demographic and physiological findings, ages and weights were 4.3 ± 1.72 years and 15.0 ± 3.71 kg in G1 and 4.8 ± 3.21 years and 17.5 ± 9.76 kg in G2. Mean end-diastolic ventricular pressures (in mm Hg) were 10.50 ± 2.86 in G1 and 10.28 ± 3.07 in G2 and the mean PVRs (in Woods units) were 1.66 ± 1.29 in G1 and 1.49 ± 0.82 in G2. The Stormy postoperative course, Fontan failure, and early mortality were all significantly higher in G2 in respect to G1 ( P value <.05). G1 mortality rate was 3.7%, 3 patients of 80, while in G2, the mortality rate was 22%, 4 patients of 18. Late Fontan failure rates were 6% for G1 patients where two patients developed pulmonary hypertension, two patients developed heart failure, and one patient had protein losing enteropathy (PLE), and 22% for the G2 patients of which two patients developed heart failure, one patient had PLE, and one patient had persistent low systemic venous saturation. Conclusions: Our results have demonstrated that patients after b-BCPA might have a tendency for worse outcomes upon Fontan completion. The b-BCPA is associated with pulmonary artery bifurcation stenosis and presents multiple sources of pulmonary blood flow where conventional PVR calculation might be imprecise and misleading since it considers the lungs as a single unit. Therefore, b-BCPA engenders correction of the conventional PVR calculation to consider each lung separately. Furthermore, the surgical approach for patients with persistent left SVC and univentricular heart should be modified.
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Affiliation(s)
- Eitan Keizman
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Shai Tejman-Yarden
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - David Mishali
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Shany Levine
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Sharon Borik
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Uri Pollak
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Uriel Katz
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Alain E. Serraf
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
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Pollak U. Heparin-induced thrombocytopenia complicating extracorporeal membrane oxygenation support in pediatric patients: review of the literature and alternative anticoagulants. Perfusion 2018; 33:7-17. [PMID: 29788841 DOI: 10.1177/0267659118766723] [Citation(s) in RCA: 12] [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] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic, immune-mediated complication of unfractionated heparin (UFH) and low molecular weight heparin therapy. HIT is characterized by moderate thrombocytopenia 5-10 days after initial heparin exposure, detection of platelet-activating anti-platelet factor 4/heparin antibodies and an increased risk of venous and arterial thrombosis. Extracorporeal membrane oxygenation (ECMO) is a form of mechanical circulatory support used in critically ill patients with respiratory or cardiac failure. Systemic anticoagulation is used to alleviate the thrombotic complications that may occur when blood is exposed to artificial surfaces within the ECMO circuit. Therefore, when HIT complicates patients on ECMO support, it is associated with a high thrombotic morbidity and mortality. The following article reviews the current knowledge in pediatric HIT, especially in ECMO patients, and the alternative anticoagulation options in the presence of HIT.
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Affiliation(s)
- Uri Pollak
- 1 Pediatric Cardiac Intensive Care Unit, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,2 Pediatric Cardiology, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,3 ECMO service, The Edmond J Safra International Congenital Heart Center; The Edmond and Lily Safra Children's Hospital; The Chaim Sheba Medical Center, Tel Hashomer, Israel.,4 The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Pollak U, Serraf A. Pediatric Cardiac Surgery and Pain Management: After 40 Years in the Desert, Have We Reached the Promised Land? World J Pediatr Congenit Heart Surg 2018; 9:315-325. [DOI: 10.1177/2150135118755977] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pain prevention in the pediatric population is mandatory and an integrative aspect of medical practice. Optimal pain management is the right of all patients and the responsibility of all health professionals. The key to adequate pain management is assessing its presence and severity, identifying those who require intervention, and appreciating treatment efficacy. The population of pediatric patients undergoing cardiac surgery is unique in both clinical severity and hemodynamic response to painful stimuli, thus making pain management even more challenging. In this review, we will describe the different pain assessment tools as well as intra- and postoperative regimens of pain management.
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Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Intensive Care Unit, The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children’s Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Pediatric Cardiology, The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children’s Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Pediatric Sedation Service, The Edmond and Lily Safra Children’s Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alain Serraf
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric and Congenital Cardiac Surgery, The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children’s Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
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Malkiel S, Eisenstadt M, Pollak U. Say a prayer for the safe cutting of a child's teeth: The folklore of teething. J Paediatr Child Health 2017; 53:1145-1148. [PMID: 28776851 DOI: 10.1111/jpc.13636] [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: 05/13/2017] [Revised: 05/15/2017] [Accepted: 05/23/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Sarah Malkiel
- Department of Pediatrics B, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Michal Eisenstadt
- Department of Pediatrics B, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Uri Pollak
- Pediatric Cardiac Intensive Care Unit, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Pollak U, Mishaly D, Kenet G, Vardi A. Heparin-induced thrombocytopenia complicating children after the Fontan procedure: Single-center experience and review of the literature. CONGENIT HEART DIS 2017; 13:16-25. [DOI: 10.1111/chd.12557] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 08/08/2017] [Revised: 10/27/2017] [Accepted: 11/06/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Uri Pollak
- Department of Pediatric Cardiac Intensive Care; The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center; Tel Aviv Israel
- Department of Pediatric Cardiology; The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center; Tel Hashomer Israel
- The Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - David Mishaly
- The Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Department of Pediatric and Congenital Cardiac Surgery; The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center; Tel Hashomer Israel
| | - Gili Kenet
- The Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- National Hemophilia Center and Institute of Thrombosis and Hemostasis, The Chaim Sheba Medical Center; Tel Hashomer Israel
| | - Amir Vardi
- Department of Pediatric Cardiac Intensive Care; The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center; Tel Aviv Israel
- The Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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Nahum E, Pollak U, Dagan O, Amir G, Frenkel G, Birk E. Predictive value of B-type natriuretic peptide level on the postoperative course of infants with congenital heart disease. Isr Med Assoc J 2013; 15:216-220. [PMID: 23841240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND B-type natriuretic peptide (BNP) has been shown to have prognostic value for morbidity and mortality after cardiac surgery. Less is known about its prognostic value in infants. OBJECTIVES To investigate the predictive value of BNP levels regarding the severity of the postoperative course in infants undergoing surgical repair of congenital heart disease. METHODS We conducted a prospective comparative study. Plasma BNP levels in infants aged 1-12 months with congenital heart disease undergoing complete repair were measured preoperatively and 8, 24 and 48 hours postoperatively. Demographic and clinical data included postoperative inotropic support and lactate level, duration of mechanical ventilation, intensive care unit (ICU) and hospitalization stay. RESULTS Cardiac surgery was performed in 19 infants aged 1-12 months. Preoperative BNP level above 170 pg/ml had a positive predictive value of 100% for inotropic score > or = 7.5 at 24 hours (specificity 100%, sensitivity 57%) and 48 hours (specificity 100%, sensitivity 100%), and was associated with longer ICU stay (P = 0.05) and a trend for longer mechanical ventilation (P = 0.12). Similar findings were found for 8 hours postoperative BNP above 1720 pg/ml. BNP level did not correlate with measured fractional shortening. CONCLUSIONS In infants undergoing heart surgery, preoperative and 8 hour BNP levels were predictive of inotropic support and longer ICU stay. These findings may have implications for preplanning ICU loads in clinical practice. Further studies with larger samples are needed.
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Affiliation(s)
- Elhanan Nahum
- Department of Pediatric Intensive Care, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.
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Pollak U, Yacobobich J, Tamary H, Dagan O, Manor-Shulman O. Heparin-induced thrombocytopenia and extracorporeal membrane oxygenation: a case report and review of the literature. J Extra Corpor Technol 2011; 43:5-12. [PMID: 21449228 PMCID: PMC4680089] [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] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 01/21/2011] [Indexed: 05/30/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated coagulation side effect of heparin therapy characterized by thrombocytopenia and by a paradoxical prothrombotic state following heparin exposure when thrombotic or thromboembolic events accurse, the condition is classified as Heparin-induced thrombocytopenia with thrombosis (HITT). We report a case of HITT with evidence of small-vessel arterial thrombosis in a 5-day-old newborn receiving extracorporeal membrane oxygenation (ECMO) for congenital diaphragmatic hernia, and our attempt of bivalirudin alternative treatment. We also review previous reports regarding HIT and ECMO with the alternative management in this unique population.
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Affiliation(s)
- Uri Pollak
- Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petah Tiqwa, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Abstract
AIM To further characterize apnoea(s) complicating bronchiolitis because of respiratory syncytial virus (RSV), to describe the incidence of this complication and identify possible risk factors for apnoea(s) and its development. METHODS The files of infants admitted to the paediatric intensive care unit (PICU) for RSV bronchiolitis during three bronchiolitis seasons (2004-2007) were reviewed for demographic, clinical and laboratory parameters. Parameters were compared between patients with and without apnoeas. RESULTS Seventy-nine patients met the study criteria: 43 were admitted to the PICU for central apnoeas and the remainder for respiratory distress or failure. The percentage of infants admitted for apnoea increased during the study period (28.6 to 77.1%, p = 0.004). The overall prevalence of apnoea in this population was 4.3%. Possible risk factors for apnoea(s) were younger age (1.3 vs. 4.3 months, p = 0.002), lower admission weight (3.3 vs. 5 kg, p < 0.001), lower gestational age (35.8 vs. 37.8 weeks, p = 0.01), admission from the emergency room (50% vs. 9.1%, p < 0.001) and lack of hyperthermia (p < 0.001). Respiratory acidosis was found to be a protective factor on logistic regression analysis. CONCLUSION The prevalence of apnoea in infants admitted to the PICU for RSV bronchiolitis in our centre may be increasing. Preterm, younger infants with no fever are at relatively high risk of apnoea at presentation, while older infants with fever are at lower risk.
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Affiliation(s)
- Ofer Schiller
- Schneider Children's Medical Center of Israel, Petah Tiqwa, Israel.
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Finkelstein Y, Aks SE, Hutson JR, Juurlink DN, Nguyen P, Dubnov-Raz G, Pollak U, Koren G, Bentur Y. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila) 2010; 48:407-14. [PMID: 20586571 DOI: 10.3109/15563650.2010.495348] [Citation(s) in RCA: 346] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Colchicine is used mainly for the treatment and prevention of gout and for familial Mediterranean fever (FMF). It has a narrow therapeutic index, with no clear-cut distinction between nontoxic, toxic, and lethal doses, causing substantial confusion among clinicians. Although colchicine poisoning is sometimes intentional, unintentional toxicity is common and often associated with a poor outcome. METHODS We performed a systematic review by searching OVID MEDLINE between 1966 and January 2010. The search strategy included "colchicine" and "poisoning" or "overdose" or "toxicity" or "intoxication." TOXICOKINETICS Colchicine is readily absorbed after oral administration, but undergoes extensive first-pass metabolism. It is widely distributed and binds to intracellular elements. Colchicine is primarily metabolized by the liver, undergoes significant enterohepatic re-circulation, and is also excreted by the kidneys. THERAPEUTIC AND TOXIC DOSES: The usual adult oral doses for FMF is 1.2-2.4 mg/day; in acute gout 1.2 mg/day and for gout prophylaxis 0.5-0.6 mg/day three to four times a week. High fatality rate was reported after acute ingestions exceeding 0.5 mg/kg. The lowest reported lethal doses of oral colchicine are 7-26 mg. DRUG INTERACTIONS CYP 3A4 and P-glycoprotein inhibitors, such as clarithromycin, erythromycin, ketoconazole, ciclosporin, and natural grapefruit juice can increase colchicine concentrations. Co-administration with statins may increase the risk of myopathy. MECHANISMS OF TOXICITY Colchicine's toxicity is an extension of its mechanism of action - binding to tubulin and disrupting the microtubular network. As a result, affected cells experience impaired protein assembly, decreased endocytosis and exocytosis, altered cell morphology, decreased cellular motility, arrest of mitosis, and interrupted cardiac myocyte conduction and contractility. The culmination of these mechanisms leads to multi-organ dysfunction and failure. REPRODUCTIVE TOXICOLOGY AND LACTATION: Colchicine was not shown to adversely affect reproductive potential in males or females. It crosses the placenta but there is no evidence of fetal toxicity. Colchicine is excreted into breast milk and considered compatible with lactation. CLINICAL FEATURES Colchicine poisoning presents in three sequential and usually overlapping phases: 1) 10-24 h after ingestion - gastrointestinal phase mimicking gastroenteritis may be absent after intravenous administration; 2) 24 h to 7 days after ingestion - multi-organ dysfunction. Death results from rapidly progressive multi-organ failure and sepsis. Delayed presentation, pre-existing renal or liver impairment are associated with poor prognosis. 3) Recovery typically occurs within a few weeks of ingestion, and is generally a complete recovery barring complications of the acute illness. DIAGNOSIS History of ingestion of tablets, parenteral administration, or consumption of colchicine-containing plants suggest the diagnosis. Colchicine poisoning should be suspected in patients with access to the drug and the typical toxidrome (gastroenteritis, hypotension, lactic acidosis, and prerenal azotemia). MANAGEMENT Timely gastrointestinal decontamination should be considered with activated charcoal, and very large, recent (<60 min) ingestions may warrant gastric lavage. Supportive treatments including administration of granulocyte colony-stimulating factor are the mainstay of treatment. Although a specific experimental treatment (Fab fragment antibodies) for colchicine poisoning has been used, it is not commercially available. CONCLUSION Although colchicine poisoning is relatively uncommon, it is imperative to recognize its features as it is associated with a high mortality rate when missed.
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Affiliation(s)
- Yaron Finkelstein
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Pollak U, Bar-Sever Z, Hoffer V, Marcus N, Scheuerman O, Garty BZ. Asplenia and functional hyposplenism in autoimmune polyglandular syndrome type 1. Eur J Pediatr 2009; 168:233-5. [PMID: 18496713 DOI: 10.1007/s00431-008-0735-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Accepted: 03/31/2008] [Indexed: 10/22/2022]
Abstract
Asplenia was diagnosed in four patients with autoimmune polyendocrine syndrome type-I (APS-I): two children, aged 2-4 years, from the same family and two adults, the father of the two children and his cousin. We have observed a worsening in splenic function in the children during a follow-up of a few years. Patients with APS-I should be evaluated for splenic function, since splenic dysfunction has important therapeutic implications, especially in children.
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Affiliation(s)
- Uri Pollak
- Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petah Tiqwa 49202, Israel
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Dubnov-Raz G, Pollak U, Nahum E, Bruckheimer E. “Cardiac apple” — On Rosh Hashanah. Int J Cardiol 2007; 115:133. [PMID: 16784788 DOI: 10.1016/j.ijcard.2006.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2005] [Accepted: 01/28/2006] [Indexed: 11/19/2022]
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Abstract
Acute hemorrhagic edema of infancy is a benign leukocytoclastic vasculitis occurring in children younger than 2 years. The etiology is unknown. Viral or bacterial infections, immunizations, and the use of several medications, mainly antibiotics, may be involved in the pathogenesis. We report the first instance of this disease associated with herpesvirus type 1 stomatitis.
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Affiliation(s)
- Ben Zion Garty
- Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petah Tiqva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Lazar L, Pollak U, Kalter-Leibovici O, Pertzelan A, Phillip M. Pubertal course of persistently short children born small for gestational age (SGA) compared with idiopathic short children born appropriate for gestational age (AGA). Eur J Endocrinol 2003; 149:425-32. [PMID: 14585089 DOI: 10.1530/eje.0.1490425] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Few data are available on the pubertal development of children born small for gestational age (SGA) who fail to show catch-up growth. DESIGN A longitudinal analysis compared the pubertal course of persistently short children born SGA compared to children with idiopathic short stature who were appropriate for gestational age (AGA). One hundred and twenty-eight short children (height SDS<-1.7), including 76 (31 boys) born SGA and 52 (22 boys) born AGA, were regularly followed from early childhood to completion of puberty. RESULTS Puberty was attained at normal age (10.5-14 Years in boys, 9.5-13 Years in girls) for most children in both the SGA and AGA groups (boys, 80% and 77%; girls, 76% and 78% respectively). The duration of puberty was similar in the SGA and AGA groups. Menarche occurred at normal age range but was significantly earlier in the SGA girls (P<0.01 by ANOVA). Despite the similar total pubertal growth, the patterns of growth differed significantly: SGA group - accelerated growth and bone maturation rates from onset of puberty with peak height velocity at Tanner stages 2-3, followed by a decelerated growth rate and earlier fusion of the epiphyses; AGA group - steady progression of bone elongation and maturation throughout puberty (pubertal growth, P<0.05 in both sexes; bone maturation, P<0.001 in both sexes). Final height in the SGA group was compromised compared with their target height (P<0.001). CONCLUSION Children born SGA have a normal pubertal course with a distinct pubertal growth pattern. This pattern may represent an altered regulation of their growth modalities.
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Affiliation(s)
- Liora Lazar
- Institute for Endocrinology and Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
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