Präoperative Azidose und Entwicklung von Säuglingen nach Operation angeborener Herzfehler

Pulmonary Overcirculation Requiring Surgical and Pulmonary Flow Restrictor Device Intervention in Critical Coarctation of the Aorta-A Case Series

The use of prostaglandin infusion to maintain patency of the ductus arteriosus in patients with critical coarctation of the aorta (CoA) to support systemic circulation is the standard of care. However, pulmonary overcirculation resulting from a patent ductus arteriosus in patients with critical CoA is not well described in the literature. We report two cases of critical CoA that required invasive measures to control pulmonary blood flow before surgical repair of the CoA. Both patients had signs of decreased oxygen delivery, hyperlactatemia, and systemic to pulmonary flow via the ductus arteriosus. One patient required surgical pulmonary artery banding and the second patient underwent pulmonary flow restrictor device placement for the control of pulmonary blood flow. A rapid improvement in oxygen delivery and normalization of lactate levels were observed after control of pulmonary overcirculation. Both patients underwent successful surgical repair of the coarctation A and were discharged home.

Association between Serum Lactate and Morbidity and Mortality in Neonates: A Systematic Review and Meta-Analysis

OBJECTIVE

Lactate is a marker of hypoperfusion in critically ill patients. Whether lactate is useful for identifying and stratifying neonates with a higher risk of adverse outcomes remains unknown. This study aimed to investigate the association between lactate and morbidity and mortality in neonates.

METHODS

A meta-analysis was performed to determine the association between blood lactate levels and outcomes in neonates. Ovid MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov were searched from inception to 1 May 2021. A total of 49 observational studies and 14 data accuracy test studies were included. The risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies and the QUADAS-2 tool for data accuracy test studies. The primary outcome was mortality, while the secondary outcomes included acute kidney injury, necessity for renal replacement therapy, neurological outcomes, respiratory morbidities, hemodynamic instability, and retinopathy of prematurity.

RESULTS

Of the 3184 articles screened, 63 studies fulfilled all eligibility criteria, comprising 46,069 neonates. Higher lactate levels are associated with mortality (standard mean difference, -1.09 [95% CI, -1.46 to -0.73]). Using the estimated sensitivity (0.769) and specificity (0.791) and assuming a prevalence of 15% for adverse outcomes (median of prevalence among studies) in a hypothetical cohort of 10,000 neonates, assessing the lactate level alone would miss 346 (3.46%) cases (false negative) and wrongly diagnose 1776 (17.76%) cases (false positive).

CONCLUSIONS

Higher lactate levels are associated with a greater risk of mortality and morbidities in neonates. However, our results do not support the use of lactate as a screening test to identify adverse outcomes in newborns. Research efforts should focus on analyzing serial lactate measurements, rather than a single measurement.

Fetal Diagnosis is Associated with Improved Perioperative Condition of Neonates Requiring Surgical Intervention for Coarctation

To define the relative importance of fetal diagnosis and comorbidities in severity of preoperative compromise, outcomes and hospitalization in neonatal coarctation of the aorta (CoA). Retrospective comparison of preoperative condition and postoperative course of neonates prenatally (PreDx n = 48) or postnatally diagnosed (PostDx n = 67) with CoA. Congenital and non-congenital comorbidities were adjusted for. Postnatal diagnosis was associated with preoperative mortality (n = 2), and severe acidosis (lactate > 5 mM or pH < 7.20) on multivariate analysis (OR 4.2 (1.3-14.4, p = 0.02), with extracardiac congenital anomalies also a risk factor (OR 3.2 (1.03-10, p = 0.044). Median age at operation was delayed in the PostDx group (PreDx 6.5 days (IQR 4-9) vs PostDx 10 days (IQR 6-17)). Only comorbid left heart disease and extracardiac congenital anomalies were associated with prolonged total length of hospital stay. Prenatal diagnosis is the major adjustable risk factor affecting preoperative condition in critical CoA but does not reduce length of stay.