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Pardo AC, Carrasco M, Wintermark P, Nunes D, Chock VY, Sen S, Wusthoff CJ. Neuromonitoring practices for neonates with congenital heart disease: a scoping review. Pediatr Res 2024:10.1038/s41390-024-03484-x. [PMID: 39183308 DOI: 10.1038/s41390-024-03484-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/30/2024] [Accepted: 08/01/2024] [Indexed: 08/27/2024]
Abstract
Neonates with congenital heart disease (CHD) are at risk for adverse neurodevelopmental outcomes. This scoping review summarizes neuromonitoring methods in neonates with CHD. We identified 84 studies investigating the use of near-infrared spectroscopy (NIRS) (n = 37), electroencephalography (EEG) (n = 20), amplitude-integrated electroencephalography (aEEG) (n = 10), transcranial Doppler sonography (TCD) (n = 6), and multimodal monitoring (n = 11). NIRS was used to evaluate cerebral oxygenation, identify risk thresholds and adverse events in the intensive care unit (ICU), and outcomes. EEG was utilized to screen for seizures and to predict adverse outcomes. Studies of aEEG have focused on characterizing background patterns, detecting seizures, and outcomes. Studies of TCD have focused on correlation with short-term clinical outcomes. Multimodal monitoring studies characterized cerebral physiologic dynamics. Most of the studies were performed in single centers, had a limited number of neonates (range 3-183), demonstrated variability in neuromonitoring practices, and lacked standardized approaches to neurodevelopmental testing. We identified areas of improvement for future research: (1) large multicenter studies to evaluate developmental correlates of neuromonitoring practices; (2) guidelines to standardize neurodevelopmental testing methodologies; (3) research to address geographic variation in resource utilization; (4) integration and synchronization of multimodal monitoring; and (5) research to establish a standardized framework for neuromonitoring techniques across diverse settings. IMPACT: This scoping review summarizes the literature regarding neuromonitoring practices in neonates with congenital heart disease (CHD). The identification of low cerebral oxygenation thresholds with NIRS may be used to identify neonates at risk for adverse events in the ICU or adverse neurodevelopmental outcomes. Postoperative neuromonitoring with continuous EEG screening for subclinical seizures and status epilepticus, allow for early and appropriate therapy. Future studies should focus on enrolling larger multicenter cohorts of neonates with CHD with a standardized framework of neuromonitoring practices in this population. Postoperative neurodevelopmental testing should utilize standard assessments and testing intervals.
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Affiliation(s)
- Andrea C Pardo
- Department of Pediatrics (Neurology and Epilepsy). Northwestern University Feinberg School of Medicine, Chicago, IL, US.
| | - Melisa Carrasco
- Department of Neurology. University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Pia Wintermark
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, Montreal, Qc, Canada
| | - Denise Nunes
- Galter Health Sciences Library. Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Valerie Y Chock
- Department of Pediatrics (Neonatology), Lucile Packard Children's Hospital and Stanford University, Palo Alto, CA, US
| | - Shawn Sen
- Department of Pediatrics (Neonatology). Northwestern University Feinberg School of Medicine, Chicago, IL, US
- Department of Pediatrics, University of California Irvine, Orange, CA, US
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2
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Leth-Olsen M, Døhlen G, Torp H, Nyrnes SA. Cerebral blood flow dynamics during cardiac surgery in infants. Pediatr Res 2024:10.1038/s41390-024-03161-z. [PMID: 38570558 DOI: 10.1038/s41390-024-03161-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/21/2023] [Accepted: 03/10/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND In this pilot study, we investigated continuous cerebral blood flow velocity measurements to explore cerebrovascular hemodynamics in infants with congenital heart disease undergoing cardiac surgery. METHODS A non-invasive transfontanellar cerebral Doppler monitor (NeoDoppler) was used to monitor 15 infants (aged eight days to nine months) during cardiac surgery with cardiopulmonary bypass. Numerical and visual analyses were conducted to assess trends and events in Doppler measurements together with standard monitoring equipment. The mean flow index, calculated as the moving Pearson correlation between mean arterial pressure and time averaged velocity, was utilized to evaluate dynamic autoregulation. Two levels of impaired autoregulation were defined (Mean flow index >0.3/0.45), and percentage of time above these limits were calculated. RESULTS High quality recordings were achieved during 90.6% of the monitoring period. There was a significant reduction in time averaged velocity in all periods of cardiopulmonary bypass. All patients showed a high percentage of time with impaired dynamic autoregulation, with Mean flow index >0.3 and 0.45: 73.71% ± 9.06% and 65.16% ± 11.27% respectively. Additionally, the system promptly detected hemodynamic events. CONCLUSION Continuous transfontanellar cerebral Doppler monitoring could become an additional tool in enhancing cerebral monitoring in infants during cardiac surgery. IMPACT This pilot study demonstrates the feasibility of continuous transfontanellar Doppler monitoring of cerebral blood flow velocities during cardiac surgery in infants. It also demonstrates a high proportion of time with impaired cerebral autoregulation during cardiac surgery based on the Mean flow index. Continuous transfontanellar Doppler could become a useful tool to improve cerebral monitoring and provide new pathophysiological insight.
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Affiliation(s)
- Martin Leth-Olsen
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.
- Children's Clinic, St Olav's University Hospital, Trondheim, Norway.
| | - Gaute Døhlen
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Hans Torp
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Siri Ann Nyrnes
- Department of Circulation and Medical Imaging (ISB), Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Children's Clinic, St Olav's University Hospital, Trondheim, Norway
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3
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Phillips K, Callaghan B, Rajagopalan V, Akram F, Newburger JW, Kasparian NA. Neuroimaging and Neurodevelopmental Outcomes Among Individuals With Complex Congenital Heart Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:2225-2245. [PMID: 38030353 DOI: 10.1016/j.jacc.2023.09.824] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/13/2023] [Indexed: 12/01/2023]
Abstract
Although neuroimaging advances have deepened our understanding of brain health in individuals with congenital heart disease (CHD), it is less clear how neuroimaging findings relate to neurodevelopmental and mental health outcomes across the lifespan. We systematically synthesized and critically evaluated evidence on associations between neuroimaging and neurodevelopmental, neurocognitive, psychiatric, or behavioral outcomes among individuals with transposition of great arteries or single-ventricle CHD (Protocol CRD42021229617). Six databases were searched and 45 papers from 25 unique studies were identified. Structural brain injury was generally linked to poorer neurodevelopment in infancy. Brain volumes and microstructural and functional brain changes appear linked to neurocognitive outcomes, including deficits in attention, learning, memory, and executive function in children and adolescents. Fetal neuroimaging studies were limited. Four papers investigated psychiatric outcomes; none found associations with neuroimaging. Multicenter, longitudinal studies incorporating functional neuroimaging and mental health outcomes are much-needed to inform early neuroprotective and therapeutic strategies in CHD.
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Affiliation(s)
- Katelyn Phillips
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bridget Callaghan
- Department of Psychology, University of California Los Angeles, Los Angeles, California, USA
| | - Vidya Rajagopalan
- Department of Radiology, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Farah Akram
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Nadine A Kasparian
- Heart and Mind Wellbeing Center, Heart Institute and the Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Fogel MA, Donnelly E, Crandell I, Hanlon A, Whitehead KK, Harris M, Partington S, Biko D, Flynn T, Nicolson S, Gaynor JW, Licht D, Vossough A. Cerebral Blood Flow, Brain Injury, and Aortic-Pulmonary Collateral Flow After the Fontan Operation. Am J Cardiol 2023; 208:164-170. [PMID: 37844519 DOI: 10.1016/j.amjcard.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/31/2023] [Accepted: 08/05/2023] [Indexed: 10/18/2023]
Abstract
Patients with a single ventricle develop aortopulmonary collaterals (APCs) whose flow has been shown to be inversely proportional to cerebral blood flow (CBF) in a previous cross-sectional study. Longitudinal CBF and APC flow in patients with Fontan physiology adjusting for brain injury (BI) has never been reported. Decreased CBF and BI may adversely impact neurodevelopment. A prospective longitudinal cohort of 27 patients with Fontan physiology (aged 10 ± 1.9 years, 74% male) underwent cardiac and brain magnetic resonance imaging 3 to 9 months and 6.0 ± 1.86 years after Fontan operation to measure the CBF and APC flow and to reassess the BI (focal BI, generalized insult, and hemorrhage). CBF was measured using jugular venous flow and APC flow was measured by the difference between aortic flow and caval return. Multivariate modeling was used to assess the relation between the change in APC flow and BI. A strong inverse relation was found between CBF/aortic flow change and APC flow/aortic flow and APC flow/body surface area change (R2 = 0.70 and 0.72 respectively, p <0.02). Overall, the CBF decreased by 9 ± 11% and the APC flow decreased by 0.73 ± 0.67 l/min/m2. The evolution of CBF and APC flow were significantly and inversely related when adjusting for time since Fontan operation, gender, and BI on the multivariate modeling. Every unit increase in APC flow change was associated with an 8% decrease in CBF change. In conclusion, CBF and APC flow change are inversely related across serial imaging, adjusting for time from Fontan operation, gender, and BI. CBF and APC aortic flow decrease over a 6-year period. This may adversely impact neurodevelopment. Because APCs can be embolized, this may be a modifiable risk factor. Clinical trials numbers: NCT02135081 and NCT02919956.
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Affiliation(s)
- Mark A Fogel
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Elizabeth Donnelly
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ian Crandell
- The Center for Biostatistics and Health Data Science, Virginia Polytechnic and State University, Roanoke, Virginia
| | - Alex Hanlon
- The Center for Biostatistics and Health Data Science, Virginia Polytechnic and State University, Roanoke, Virginia
| | - Kevin K Whitehead
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Matthew Harris
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Sara Partington
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - David Biko
- Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Thomas Flynn
- Division of Integrated Behavioral Medicine, Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Susan Nicolson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Daniel Licht
- Division of Neurology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Arastoo Vossough
- Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Soares C, Vieira RJ, Costa S, Moita R, Andrade M, Guimarães H. Neurodevelopment outcomes in the first 5 years of the life of children with transposition of the great arteries surgically corrected in the neonatal period: systematic review and meta-analysis. Cardiol Young 2023; 33:2471-2480. [PMID: 37965690 DOI: 10.1017/s104795112300375x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
OBJECTIVES In patients with transposition of the great arteries, surgical correction may achieve definitive treatment, so a thorough knowledge of the long-term outcomes, particularly neurodevelopment outcomes, is essential. Therefore, we conducted a systematic review and meta-analysis to study the neurodevelopment outcomes in the first 5 years of the life of children submitted to corrective surgery for transposition of the great arteries in the neonatal period. METHODS A total of 17 studies from 18 reports were included, assessing 809 individuals with surgically corrected transposition of the great arteries. The neurodevelopmental outcomes were assessed with the Bayley Scales of Infant and Toddler Development (BSID) and the Wechsler Intelligence Scale for Children (WISC). RESULTS Mean Mental Development Index (MDI) and Psychomotor Development Index (PDI) were within the average values from 1 to 3 years of age, although the proportion of children scoring more than 1 standard deviation below the mean in PDI, MDI, motor, and language composite scores was significantly higher than in the general population. From 4 to 5 years, mean full-scale global intelligence quotient (IQ), verbal IQ, and performance IQ scores did not differ significantly from the general population. CONCLUSION This study revealed neurodevelopment scores within the normal range at 5 years of age in children submitted to corrective surgery for transposition of the great arteries in the neonatal period. However, these early outcomes may not adequately predict long-term outcomes. Further studies are needed to identify specific risk factors and early markers of later impairment to guide the establishment of early interventions.
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Affiliation(s)
| | - Rafael José Vieira
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of Porto University, Porto, Portugal
- Centre for Health Technology and Services Research, Health Research Network (CINTESIS@RISE), Faculty of Medicine of Porto University, Porto, Portugal
| | - Sandra Costa
- Faculty of Medicine of Porto University, Porto, Portugal
- Neonatology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Rita Moita
- Neonatology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Mariana Andrade
- Pediatrics Department, Centro Hospitalar Universitário São João, Porto, Portugal
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6
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Reighard C, Junaid S, Jackson WM, Arif A, Waddington H, Whitehouse AJO, Ing C. Anesthetic Exposure During Childhood and Neurodevelopmental Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2217427. [PMID: 35708687 PMCID: PMC9204549 DOI: 10.1001/jamanetworkopen.2022.17427] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/29/2022] [Indexed: 01/05/2023] Open
Abstract
Importance Clinical studies of neurodevelopmental outcomes after anesthetic exposure have evaluated a range of outcomes with mixed results. Objective To examine via meta-analyses the associations between exposure to general anesthesia and domain-specific neurodevelopmental outcomes in children. Data Sources PubMed/MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library were searched from inception to August 31, 2021. Study Selection Inclusion criteria were exposures to procedures requiring general anesthesia at younger than 18 years and evaluation of long-term neurodevelopmental function after exposure. Studies lacking unexposed controls or focused on children with major underlying comorbidities were excluded. Data Extraction and Synthesis Extracted variables included effect size; hazard, risk, or odds ratio; number of exposures; procedure type; major comorbidities; age of exposure and assessment; presence of unexposed controls; and study design. Studies were independently reviewed by 2 coders, and review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were pooled using a random-effects model. Main Outcomes and Measures The main outcomes were standardized mean differences (SMD) for scores in the neurodevelopmental domains of academics, behavioral problems, cognition, executive function, general development, language, motor function, nonverbal reasoning, social cognition, and hazard and risk of neurodevelopmental disorder diagnoses. Results A total of 31 studies contributed data for meta-analysis. For each of the assessed neurodevelopmental domains, the numbers of children evaluated ranged from 571 to 63 315 exposed and 802 to 311 610 unexposed. Children with any exposure (single or multiple) had significantly worse behavioral problems scores, indicating more behavioral problems (SMD, -0.10; 95% CI, -0.18 to -0.02; P = .02), and worse scores in academics (SMD, -0.07; 95% CI -0.12 to -0.01; P = .02), cognition (SMD, -0.03; 95% CI, -0.05 to 0.00; P = .03), executive function (SMD, -0.20; 95% CI, -0.32 to -0.09; P < .001), general development (SMD, -0.08; 95% CI, -0.13 to -0.02; P = .01), language (SMD, -0.08; 95% CI, -0.14 to -0.02; P = .01), motor function (SMD, -0.11; 95% CI, -0.21 to -0.02; P = .02), and nonverbal reasoning (SMD, -0.15; 95% CI, -0.27 to -0.02; P = .02). Higher incidences of neurodevelopmental disorder diagnoses were also reported (hazard ratio, 1.19; 95% CI, 1.09 to 1.30; P < .001; risk ratio, 1.81; 95% CI, 1.25 to 2.61; P = .002). Conclusions and Relevance These findings support the hypothesis that associations between anesthetic exposure during childhood and subsequent neurodevelopmental deficits differ based on neurodevelopmental domain.
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Affiliation(s)
- Charles Reighard
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Shaqif Junaid
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - William M. Jackson
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Ayesha Arif
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Hannah Waddington
- Faculty of Education, Victoria University of Wellington, Wellington, New Zealand
| | | | - Caleb Ing
- Department of Anesthesiology and Epidemiology, Columbia University Vagelos College of Physicians and Surgeons and Mailman School of Public Health, New York, New York
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Schmithorst VJ, Badaly D, Beers SR, Lee VK, Weinberg J, Lo CW, Panigrahy A. Relationships Between Regional Cerebral Blood Flow and Neurocognitive Outcomes in Children and Adolescents With Congenital Heart Disease. Semin Thorac Cardiovasc Surg 2022; 34:1285-1295. [PMID: 34767938 PMCID: PMC9085965 DOI: 10.1053/j.semtcvs.2021.10.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 01/03/2023]
Abstract
To identify regional cerebral blood flow (rCBF) alterations in children and adolescents with congenital heart disease (CHD) in relation to neurocognitive outcomes using a nonbiased data-driven approach. This is a prospective, observational study of children and adolescents with CHD without brain injury and healthy controls using pseudo-continuous arterial spin labeling (pCASL) MRI. Quantitative rCBF was compared between participants with CHD and healthy controls using a voxelwise data-driven method. Mediation analysis was then performed on a voxelwise basis, with the grouping variable as the independent variable, neurocognitive outcomes (from the NIH Toolbox Cognitive Battery) as the dependent variables, and rCBF as the mediator. After motion correction, a total of 80 studies were analyzable (27 for patients with CHD, 53 for controls). We found steeper age-related decline in rCBF among those with CHD compared to normal controls in the insula/ventromedial prefrontal regions (salience network) and the dorsal anterior cingulate and precuneus/posterior cingulate (default mode network), and posterior parietal/dorsolateral prefrontal (central executive network) (FWE-corrected P< 0.05). The reduced rCBF in the default mode/salience network was found to mediate poorer performance on an index of crystallized cognition from the NIH Toolbox Cognitive Battery in those with CHD compared to controls. In contrast, reduced rCBF in the central executive network/salience network mediated reduced deficits in fluid cognition among patients with CHD compared to controls. Regional cerebral blood flow alterations mediate domain-specific differences in cognitive performance in children and adolescents with CHD compared to healthy controls, independent of injury, and are likely related to brain and cognitive reserve mechanisms. Further research is needed to evaluate the potential of interventions in CHD targeting regional cerebral blood flow across lifespan.
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Affiliation(s)
| | | | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine
| | - Vincent K. Lee
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh
| | | | - Cecilia W. Lo
- Department of Developmental Biology, University of Pittsburgh
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh,Department of Biomedical Informatics, University of Pittsburgh School of Medicine
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Sprong MCA, Broeders W, van der Net J, Breur JMPJ, de Vries LS, Slieker MG, van Brussel M. Motor Developmental Delay After Cardiac Surgery in Children With a Critical Congenital Heart Defect: A Systematic Literature Review and Meta-analysis. Pediatr Phys Ther 2021; 33:186-197. [PMID: 34618742 DOI: 10.1097/pep.0000000000000827] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE To systematically review evidence regarding the severity and prevalence of motor development in children with a critical congenital heart defect (CCHD) without underlying genetic anomalies. SUMMARY OF KEY POINTS Twelve percent of all included studies reported abnormal mean motor developmental scores, and 38% reported below average motor scores. Children with single-ventricle physiology, especially those with hypoplastic left heart syndrome, had the highest severity and prevalence of motor delay, particularly at 0 to 12 months. Most included studies did not differentiate between gross and fine motor development, yet gross motor development was more affected. RECOMMENDATIONS FOR CLINICAL PRACTICE We recommend clinicians differentiate between the type of heart defect, fine and gross motor development, and the presence of genetic anomalies. Furthermore, increased knowledge about severity and prevalence will enable clinicians to tailor their interventions to prevent motor development delays in CCHD.
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Affiliation(s)
- Maaike C A Sprong
- Center for Child Development, Exercise and Physical literacy (Mrs/Ms Sprong, Mr Broeders, Dr van Brussel, and Dr van der Net), Pediatric Cardiology (Dr Breur and Dr Slieker), and Department of Neonatology (Dr de Vries), Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
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9
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Millet A, Evain JN, Desrumaux A, Francony G, Bouzat P, Mortamet G. Clinical applications of transcranial Doppler in non-trauma critically ill children: a scoping review. Childs Nerv Syst 2021; 37:2759-2768. [PMID: 34244843 DOI: 10.1007/s00381-021-05282-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/29/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Many applications of transcranial Doppler (TCD) as a diagnosis or monitoring tool have raised interest in the last decades. It is important that clinicians know when and how to perform TCD in this population, what parameter to assess and monitor and how to interpret it. OBJECTIVE This review aims to describe the emerging clinical applications of TCD in critically ill children excluding those suffering from trauma. METHODS Databases Web of Science, Cochrane and PubMed were searched in May 2020. We considered all publications since the year 2000 addressing the use of TCD as a prognostic, diagnostic or follow-up tool in children aged 0 to 15 years admitted to intensive care or emergency units, excluding neonatology and traumatic brain injury. Two independent reviewers selected 82 abstracts and full-text articles from the 2011 unique citations identified at the outset. RESULTS TCD provides crucial additional information at bedside about cerebrovascular hemodynamics. Many clinical applications include the diagnosis and management of various medical and surgical neurologic conditions (central nervous system infections, arterial ischemic stroke, subarachnoid hemorrhage and vasospasm, brain death, seizures, metabolic disease, hydrocephalus) as well as monitoring the impact systemic conditions on brain perfusion (hemodynamic instability, circulatory assistance). CONCLUSION To conclude, TCD has become an invaluable asset for non-invasive neuromonitoring in critically ill children excluding those suffering from trauma. However, the scope of TCD remains unclearly defined yet and reference values in critically ill children are still lacking.
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Affiliation(s)
- Anne Millet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Jean-Noël Evain
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - Amélie Desrumaux
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Gilles Francony
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - Pierre Bouzat
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France.
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10
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O'Brien NF, Reuter-Rice K, Wainwright MS, Kaplan SL, Appavu B, Erklauer JC, Ghosh S, Kirschen M, Kozak B, Lidsky K, Lovett ME, Mehollin-Ray AR, Miles DK, Press CA, Simon DW, Tasker RC, LaRovere KL. Practice Recommendations for Transcranial Doppler Ultrasonography in Critically Ill Children in the Pediatric Intensive Care Unit: A Multidisciplinary Expert Consensus Statement. J Pediatr Intensive Care 2021; 10:133-142. [PMID: 33884214 PMCID: PMC8052112 DOI: 10.1055/s-0040-1715128] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/12/2020] [Indexed: 12/16/2022] Open
Abstract
Transcranial Doppler ultrasonography (TCD) is being used in many pediatric intensive care units (PICUs) to aid in the diagnosis and monitoring of children with known or suspected pathophysiological changes to cerebral hemodynamics. Standardized approaches to scanning protocols, interpretation, and documentation of TCD examinations in this setting are lacking. A panel of multidisciplinary clinicians with expertise in the use of TCD in the PICU undertook a three-round modified Delphi process to reach unanimous agreement on 34 statements and then create practice recommendations for TCD use in the PICU. Use of these recommendations will help to ensure that high quality TCD images are captured, interpreted, and reported using standard nomenclature. Furthermore, use will aid in ensuring reproducible and meaningful study results between TCD practitioners and across PICUs.
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Affiliation(s)
- Nicole Fortier O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Ohio, United States
| | - Karin Reuter-Rice
- Department of Pediatrics, Division of Pediatric Critical Care, School of Medicine, School of Nursing, Duke University, Duke Institute for Brain Sciences, North Carolina, United States
| | - Mark S. Wainwright
- Department of Neurology, University of Washington, Seattle Children's Hospital, Washington, United States
| | - Summer L. Kaplan
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Brian Appavu
- Department of Pediatrics, Division of Critical Care Medicine, Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine—Phoenix, Arizona, United States
| | - Jennifer C. Erklauer
- Department of Pediatrics, Division of Critical Care Medicine and Neurology, Baylor College of Medicine, Texas Children's Hospital, Texas, United States
| | - Suman Ghosh
- Department of Pediatrics, Division of Pediatric Neurology, University of Florida, College of Medicine, Florida, United States
| | - Matthew Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Brandi Kozak
- Department of Radiology, Ultrasound Division, Center for Pediatric Contrast Ultrasound, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Karen Lidsky
- Department of Pediatrics, Division of Pediatric Critical Care, Wolfson Children's Hospital, University of Florida, Florida, United States
| | - Marlina Elizabeth Lovett
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Ohio, United States
| | - Amy R. Mehollin-Ray
- Department of Radiology, Baylor College of Medicine, E.B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Texas, United States
| | - Darryl K. Miles
- Department of Pediatrics/Division of Critical Care, UT Southwestern Medical Center, Texas, United States
| | - Craig A. Press
- Department of Pediatrics, Section of Child Neurology, University of Colorado, Children's Hospital Colorado, Colorado, United States
| | - Dennis W. Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pennsylvania, United States
| | - Robert C. Tasker
- Departments of Neurology & Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Massachusetts, United States
| | - Kerri Lynn LaRovere
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Massachusetts, United States
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11
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Kussman BD, Imaduddin SM, Gharedaghi MH, Heldt T, LaRovere K. Cerebral Emboli Monitoring Using Transcranial Doppler Ultrasonography in Adults and Children: A Review of the Current Technology and Clinical Applications in the Perioperative and Intensive Care Setting. Anesth Analg 2021; 133:379-392. [PMID: 33764341 DOI: 10.1213/ane.0000000000005417] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transcranial Doppler (TCD) ultrasonography is the only noninvasive bedside technology for the detection and monitoring of cerebral embolism. TCD may identify patients at risk of acute and chronic neurologic injury from gaseous or solid emboli. Importantly, a window of opportunity for intervention-to eliminate the source of the emboli and thereby prevent subsequent development of a clinical or subclinical stroke-may be identified using TCD. In this review, we discuss the application of TCD sonography in the perioperative and intensive care setting in adults and children known to be at increased risk of cerebral embolism. The major challenge for evaluation of emboli, especially in children, is the need to establish the ground truth and define true emboli identified by TCD. This requires the development and validation of a predictive TCD emboli monitoring technique so that appropriately designed clinical studies intended to identify specific modifiable factors and develop potential strategies to reduce pathologic cerebral embolic burden can be performed.
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Affiliation(s)
- Barry D Kussman
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Syed M Imaduddin
- Department of Electrical Engineering and Computer Science, the Institute for Medical Engineering and Science, and the Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Mohammad Hadi Gharedaghi
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Thomas Heldt
- Department of Electrical Engineering and Computer Science, the Institute for Medical Engineering and Science, and the Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Kerri LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.,Department of Neurology, Harvard Medical School, Boston, Massachusetts
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12
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Zhang W, Xie S, Han D, Ou-Yang C, Lu J, Huang J. Effect of End-Tidal Carbon Dioxide on Cerebral Dynamics in Infants With Ventricular Septal Defect: A Comparison Between Sevoflurane and Intravenous Anesthetics. J Cardiothorac Vasc Anesth 2020; 34:1558-1564. [PMID: 32139343 DOI: 10.1053/j.jvca.2020.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The primary aim was to compare the changes in regional cerebral oxygen saturation (rSO2) and cerebral blood flow velocity (CBFV) during sevoflurane and intravenous anesthesia when the end-tidal carbon dioxide partial pressure (PETCO2) changed in infants undergoing ventricular septal defect (VSD) repair. DESIGN Prospective, observational study. SETTING Tertiary care hospital. PARTICIPANTS Patients younger than 6 months with VSDs. INTERVENTIONS End-tidal carbon dioxide was increased by decreasing tidal volume or respiratory rate. MEASUREMENTS AND MAIN RESULTS The infants were randomly assigned to receive either sevoflurane (SA group) or midazolam-sufentanil based intravenous anesthesia (IA group). PETCO2 levels of 30 mmHg (T1), 35 mmHg (T2), 40 mmHg (T3), or 45 mmHg (T4) were obtained by adjusting the tidal volume and respiratory rate. There were no significant intergroup differences in rSO2. In the SA group, as PETCO2 increased from T1 to T4, rSO2 increased significantly from 68.8% ± 5.9% to 76.4% ± 6.0% (p < 0.001). CBFV increased linearly, whereas the pulsatility index and resistance index decreased linearly from T1 to T4 (p < 0.001). In the IA group, rSO2 showed a significant increase from 68.6% ± 4.6% to 76.1% ± 6.2% with the change in PETCO2 from T1 to T4 (p < 0.001). CBFV increased linearly, whereas the pulsatility index and resistance index decreased linearly from T1 to T4 (p < 0.001). CONCLUSION Cerebrovascular response to different PETCO2 levels was preserved and similar during clinically relevant doses of sevoflurane anesthesia and midazolam-sufentanil based intravenous anesthesia in infants younger than 6 months old undergoing VSD repair.
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Affiliation(s)
- Weizhi Zhang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Siyuan Xie
- Anesthesia Department, Capital Institute of Pediatrics affiliated Children's Hospital, Beijing, China
| | - Ding Han
- Anesthesia Department, Capital Institute of Pediatrics affiliated Children's Hospital, Beijing, China
| | - Chuan Ou-Yang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Jiakai Lu
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China.
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
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13
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Effects of relative low minute ventilation on cerebral haemodynamics in infants undergoing ventricular septal defect repair. Cardiol Young 2020; 30:205-212. [PMID: 31937383 DOI: 10.1017/s1047951119003135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Ventilation-associated changes in blood carbon dioxide levels are associated with various physiological changes in infants undergoing surgery. Studies on the effects of mechanical ventilation on cerebral haemodynamics especially for infants with CHD are scarce. AIM This study was done to compare the changes in regional cerebral oxygen saturation and cerebral blood flow velocity when the end-tidal carbon dioxide partial pressure changed during different minute ventilation settings in infants undergoing ventricular septal defect repair. METHODS A total of 67 patients less than 1 year old with ventricular septal defect were enrolled, and 65 patients (age: 6.7 ± 3.4 months, weight: 6.4 ± 1.5 kg) were studied. After anaesthesia induction and endotracheal intubation, the same mechanical ventilation mode (The fraction of inspired oxygen was 50%, and the inspiratory-to-expiratory ratio was 1:1.5.) was adopted. The end-tidal carbon dioxide partial pressure of 30 mmHg (T1), 35 mmHg (T2), 40 mmHg (T3), or 45 mmHg (T4) were obtained, respectively, by adjusting tidal volume and respiratory rate. Minute ventilation per kilogram was calculated by the formula: minute ventilation per kilogram = tidal volume * respiratory rate/kg. Regional cerebral oxygen saturation was monitored by real-time near-infrared spectroscopy. Cerebral blood flow velocity (systolic flow velocity, end-diastolic flow velocity, and mean flow velocity), pulsatility index, and resistance index were measured intermittently by transcranial Doppler. Systolic pressure, diastolic pressure, stroke volume index, and cardiac index were recorded using the pressure recording analytical method. RESULTS As the end-tidal carbon dioxide partial pressure increased from 30 to 45 mmHg, regional cerebral oxygen saturation increased significantly from 69 ± 5% to 79 ± 4% (p < 0.001). Cerebral blood flow velocity (systolic flow velocity, end-diastolic flow velocity, and mean flow velocity) increased linearly, while pulsatility index and resistance index decreased linearly from T1 (systolic flow velocity, 84 ± 19 cm/second; end-diastolic flow velocity, 14 ± 4 cm/second; mean flow velocity, 36 ± 10 cm/second; pulsatility index, 2.13 ± 0.59; resistance index, 0.84 ± 0.12) to T4 (systolic flow velocity, 113 ± 22 cm/second; end-diastolic flow velocity, 31 ± 6 cm/second; mean flow velocity, 58 ± 11 cm/second; pulsatility index, 1.44 ± 0.34; resistance index, 0.72 ± 0.07) (p < 0.001). There were significant differences in changes of systolic flow velocity, end-diastolic flow velocity, mean flow velocity, pulsatility index, and resistance index as the end-tidal carbon dioxide partial pressure increased from 30 to 45 mmHg between subgroups of infants ≤6 and infants >6 months, while the changes of regional cerebral oxygen saturation between subgroups were not statistically different. Regional cerebral oxygen saturation and cerebral blood flow velocity (systolic flow velocity, end-diastolic flow velocity, and mean flow velocity) were negatively correlated with minute ventilation per kilogram (r = -0.538, r = -0.379, r = -0.504, r = -0.505, p < 0.001). Pulsatility index and resistance index were positively related to minute ventilation per kilogram (r = 0.464, r = 0.439, p < 0.001). The diastolic pressure was significantly reduced from T1 (41 ± 7 mmHg) to T4 (37 ± 6 mmHg) (p < 0.001). There were no significant differences in systolic pressure, stroke volume index, and cardiac index with the change of end-tidal carbon dioxide partial pressure from T1 to T4 (p = 0.063, p = 0.382, p = 0.165, p > 0.05). CONCLUSION A relative low minute ventilation strategy increases regional cerebral oxygen saturation and cerebral blood flow, which may improve cerebral oxygenation and brain perfusion in infants undergoing ventricular septal defect repair.
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14
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Walkden GJ, Pickering AE, Gill H. Assessing Long-term Neurodevelopmental Outcome Following General Anesthesia in Early Childhood: Challenges and Opportunities. Anesth Analg 2019; 128:681-694. [PMID: 30883414 PMCID: PMC6436726 DOI: 10.1213/ane.0000000000004052] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurodegeneration has been reported in young animals after exposure to all commonly used general anesthetic agents. The brain may be particularly vulnerable to anesthetic toxicity during peak synaptogenesis (in gestation and infancy). Human studies of long-term neurodevelopmental outcome following general anesthesia in early childhood report contradictory findings. This review assesses the strengths and deficiencies in human research methodologies to inform future studies. We identified 76 studies, published between 1990 and 2017, of long-term neurodevelopmental outcome following early childhood or in utero general anesthesia exposure: 49 retrospective, 9 ambidirectional, 17 prospective cohort studies, and 1 randomized controlled trial. Forty-nine studies were explicitly concerned with anesthetic-induced neurotoxicity. Full texts were appraised for methodological challenges and possible solutions. Major challenges identified included delineating effects of anesthesia from surgery, defining the timing and duration of exposure, selection of a surgical cohort and intervention, addressing multiple confounding life course factors, detecting modest neurotoxic effects with small sample sizes (median, 131 children; interquartile range, 50–372), selection of sensitive neurodevelopmental outcomes at appropriate ages for different developmental domains, insufficient length of follow-up (median age, 6 years; interquartile range, 2–12 years), and sample attrition. We discuss potential solutions to these challenges. Further adequately powered, multicenter, prospective randomized controlled trials of anesthetic-induced neurotoxicity in children are required. However, we believe that the inherent methodological challenges of studying anesthetic-induced neurotoxicity necessitate the parallel use of well-designed observational cohort studies.
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Affiliation(s)
- Graham J Walkden
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Anthony E Pickering
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Hannah Gill
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom.,Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Bristol, United Kingdom
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15
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Fang A, Allen KY, Marino BS, Brady KM. Neurologic outcomes after heart surgery. Paediatr Anaesth 2019; 29:1086-1093. [PMID: 31532867 DOI: 10.1111/pan.13744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 09/05/2019] [Accepted: 09/14/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Amy Fang
- Anesthesia, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Kiona Y Allen
- Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago, Chicago, IL, USA
| | - Bradley S Marino
- Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago, Chicago, IL, USA
| | - Ken M Brady
- Anesthesia, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine Chicago, Chicago, IL, USA
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16
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Raffaeli G, Ghirardello S, Passera S, Mosca F, Cavallaro G. Oxidative Stress and Neonatal Respiratory Extracorporeal Membrane Oxygenation. Front Physiol 2018; 9:1739. [PMID: 30564143 PMCID: PMC6288438 DOI: 10.3389/fphys.2018.01739] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/19/2018] [Indexed: 12/16/2022] Open
Abstract
Oxidative stress is a frequent condition in critically ill patients, especially if exposed to extracorporeal circulation, and it is associated with worse outcomes and increased mortality. The inflammation triggered by the contact of blood with a non-endogenous surface, the use of high volumes of packed red blood cells and platelets transfusion, the risk of hyperoxia and the impairment of antioxidation systems contribute to the increase of reactive oxygen species and the imbalance of the redox system. This is responsible for the increased production of superoxide anion, hydrogen peroxide, hydroxyl radicals, and peroxynitrite resulting in increased lipid peroxidation, protein oxidation, and DNA damage. The understanding of the pathophysiologic mechanisms leading to redox imbalance would pave the way for the future development of preventive approaches. This review provides an overview of the clinical impact of the oxidative stress during neonatal extracorporeal support and concludes with a brief perspective on the current antioxidant strategies, with the aim to focus on the potential oxidative stress-mediated cell damage that has been implicated in both short and long-term outcomes.
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Affiliation(s)
- Genny Raffaeli
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Stefano Ghirardello
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sofia Passera
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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17
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Clausen N, Kähler S, Hansen T. Systematic review of the neurocognitive outcomes used in studies of paediatric anaesthesia neurotoxicity. Br J Anaesth 2018; 120:1255-1273. [DOI: 10.1016/j.bja.2017.11.107] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/22/2017] [Accepted: 11/21/2017] [Indexed: 01/08/2023] Open
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18
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Petersen J, Kazakov A, Böhm M, Schäfers HJ, Laufs U, Abdul-Khaliq H. Cardiopulmonary bypass reduces myocardial oxidative stress, inflammation and increases c-kit +CD45 - cell population in newborns. J Transl Med 2018; 16:111. [PMID: 29703225 PMCID: PMC5921779 DOI: 10.1186/s12967-018-1478-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/07/2018] [Indexed: 12/12/2022] Open
Abstract
Background The aim of this study was to characterize the influence of cardiopulmonary bypass (CPB) on myocardial remodeling in newborns and children. Methods Biopsies from the right atrium were taken before and after CPB from 4 newborns (5–11 days old) and 7 children (8 months–16 years old). Immunostainings on 10 µm heart tissue frozen sections were performed to detect c-kit+ cells, leukocytes (CD45+ cells), Ki67+ cycling cells. The percentage of 8-hydroxy-guanosine (8-dOHG)+cardiomyocytes and non-cardiomyocytes [(8-dOHG)+-index] were determined to quantify oxidative stress. Results Δ c-kit+CD45− cells (resident cardiac stem cells) were increased in newborns (2.2 ± 1.9/mm2) and decreased in children − 1.5 ± 0.7/mm2, p < 0.01. The (8-dOHG)+-index was reduced by 43% in newborns and by 20% in children. CPB did not influence cardiac cell turnover; high cell proliferation was seen in newborns before and after CPB. Cardiopulmonary bypass significantly decreased the leucocyte infiltration in newborns to 40 ± 8%, p < 0.05, but not in children. Infiltration with eosinophils (eosinophils/CD45%) was completely abolished in the myocardium of newborns p < 0.05 and reduced to 22 ± 8% in children after CPB, n.s. Conclusions Immediate response and remodeling of the myocardium to CPB differs between newborns, older infants and children. Especially an increased number of c-kit expressing CD45 cells after CPB were seen in neonates in comparison to children. The clinical value of such observation needs to be further assessed in larger cohorts of patients. Electronic supplementary material The online version of this article (10.1186/s12967-018-1478-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johannes Petersen
- Department of Pediatric Cardiology, Saarland University Medical Center, 66421, Homburg/Saar, Germany.,Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Andrey Kazakov
- Department of Cardiology, Angiology and Intensive Care Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Michael Böhm
- Department of Cardiology, Angiology and Intensive Care Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Ulrich Laufs
- Department of Cardiology, University Medical Center Leipzig, Leipzig, Germany
| | - Hashim Abdul-Khaliq
- Department of Pediatric Cardiology, Saarland University Medical Center, 66421, Homburg/Saar, Germany.
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19
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Ing RJ, Twite MD. Toward Improved Neurodevelopmental Outcomes: The Role of Transfontanel Ultrasound Assessment of Cerebral Blood Flow in Infants Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 32:1655-1656. [PMID: 29501227 DOI: 10.1053/j.jvca.2018.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Richard J Ing
- Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Mark D Twite
- Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
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20
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Stout JN, Tisdall MD, McDaniel P, Gagoski B, Bolar DS, Grant PE, Adalsteinsson E. Assessing the effects of subject motion on T 2 relaxation under spin tagging (TRUST) cerebral oxygenation measurements using volume navigators. Magn Reson Med 2017; 78:2283-2289. [PMID: 28247427 PMCID: PMC5573669 DOI: 10.1002/mrm.26616] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/02/2016] [Accepted: 12/28/2016] [Indexed: 12/16/2022]
Abstract
PURPOSE Subject motion may cause errors in estimates of blood T2 when using the T2 -relaxation under spin tagging (TRUST) technique on noncompliant subjects like neonates. By incorporating 3D volume navigators (vNavs) into the TRUST pulse sequence, independent measurements of motion during scanning permit evaluation of these errors. METHODS The effects of integrated vNavs on TRUST-based T2 estimates were evaluated using simulations and in vivo subject data. Two subjects were scanned with the TRUST+vNav sequence during prescribed movements. Mean motion scores were derived from vNavs and TRUST images, along with a metric of exponential fit quality. Regression analysis was performed between T2 estimates and mean motion scores. Also, motion scores were determined from independent neonatal scans. RESULTS vNavs negligibly affected venous blood T2 estimates and better detected subject motion than fit quality metrics. Regression analysis showed that T2 is biased upward by 4.1 ms per 1 mm of mean motion score. During neonatal scans, mean motion scores of 0.6 to 2.0 mm were detected. CONCLUSION Motion during TRUST causes an overestimate of T2 , which suggests a cautious approach when comparing TRUST-based cerebral oxygenation measurements of noncompliant subjects. Magn Reson Med 78:2283-2289, 2017. © 2017 International Society for Magnetic Resonance in Medicine.
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Affiliation(s)
- Jeffrey N. Stout
- Harvard-MIT Health Sciences and Technology, Institute for Medical
Engineering & Science, MIT, Cambridge, MA, United States
| | - M. Dylan Tisdall
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts
General Hospital, Charlestown, MA, United States
- Radiology, Harvard Medical School, Boston, MA, United States
| | - Patrick McDaniel
- Department of Electrical Engineering and Computer Science, MIT,
Cambridge, MA, United States
| | - Borjan Gagoski
- Department of Radiology, Boston Children’s Hospital, Boston
MA, United States
| | - Divya S. Bolar
- Department of Radiology, Massachusetts General Hospital, Boston, MA,
United States
| | - Patricia Ellen Grant
- Department of Radiology, Boston Children’s Hospital, Boston
MA, United States
- Department of Pediatrics, Boston Children’s Hospital, Boston
MA, United States
| | - Elfar Adalsteinsson
- Harvard-MIT Health Sciences and Technology, Institute for Medical
Engineering & Science, MIT, Cambridge, MA, United States
- Department of Electrical Engineering and Computer Science, MIT,
Cambridge, MA, United States
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21
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Abu-Halima M, Poryo M, Ludwig N, Mark J, Marsollek I, Giebels C, Petersen J, Schäfers HJ, Grundmann U, Pickardt T, Keller A, Meese E, Abdul-Khaliq H. Differential expression of microRNAs following cardiopulmonary bypass in children with congenital heart diseases. J Transl Med 2017; 15:117. [PMID: 28558735 PMCID: PMC5450060 DOI: 10.1186/s12967-017-1213-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 05/16/2017] [Indexed: 11/10/2022] Open
Abstract
Background Children with congenital heart defects (CHDs) are at high risk for myocardial failure after operative procedures with cardiopulmonary bypass (CPB). Recent studies suggest that microRNAs (miRNA) are involved in the development of CHDs and myocardial failure. Therefore, the aim of this study was to determine alterations in the miRNA profile in heart tissue after cardiac surgery using CPB. Methods In total, 14 tissue samples from right atrium were collected from patients before and after connection of the CPB. SurePrint™ 8 × 60K Human v21 miRNA array and quantitative reverse transcription-polymerase chain reaction (RT-qPCR) were employed to determine the miRNA expression profile from three patients before and after connection of the CPB. Enrichment analyses of altered miRNA expression were predicted using bioinformatic tools. Results According to miRNA array, a total of 90 miRNAs were significantly altered including 29 miRNAs with increased and 61 miRNAs with decreased expression after de-connection of CPB (n = 3) compared to before CPB (n = 3). Seven miRNAs had been validated using RT-qPCR in an independent cohort of 11 patients. Enrichment analyses applying the KEGG database displayed the highest correlation for signaling pathways, cellular community, cardiovascular disease and circulatory system. Conclusion Our result identified the overall changes of the miRNome in right atrium tissue of patients with CHDs after CPB. The differentially altered miRNAs lay a good foundation for further understanding of the molecular function of changed miRNAs in regulating CHDs and after CPB in particular. Electronic supplementary material The online version of this article (doi:10.1186/s12967-017-1213-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Masood Abu-Halima
- Department of Human Genetics, Saarland University, 66421, Homburg/Saar, Germany. .,Department of Human Genetics, Saarland University Medical Center, 66421, Homburg/Saar, Germany.
| | - Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, 66421, Homburg/Saar, Germany
| | - Nicole Ludwig
- Department of Human Genetics, Saarland University, 66421, Homburg/Saar, Germany
| | - Janine Mark
- Department of Pediatric Cardiology, Saarland University Medical Center, 66421, Homburg/Saar, Germany
| | - Ina Marsollek
- Department of Pediatric Cardiology, Saarland University Medical Center, 66421, Homburg/Saar, Germany
| | - Christian Giebels
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, 66421, Homburg/Saar, Germany
| | - Johannes Petersen
- Department of Pediatric Cardiology, Saarland University Medical Center, 66421, Homburg/Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, 66421, Homburg/Saar, Germany
| | - Ulrich Grundmann
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center, 66421, Homburg/Saar, Germany
| | - Thomas Pickardt
- Competence Network for Congenital Heart Defects, National Register for Congenital Heart Defects, DZHK, 13347, Berlin, Germany
| | - Andreas Keller
- Department of Clinical Bioinformatics, Saarland University, 66041, Saarbruecken, Germany
| | - Eckart Meese
- Department of Human Genetics, Saarland University, 66421, Homburg/Saar, Germany
| | - Hashim Abdul-Khaliq
- Department of Pediatric Cardiology, Saarland University Medical Center, 66421, Homburg/Saar, Germany.,Competence Network for Congenital Heart Defects, National Register for Congenital Heart Defects, DZHK, 13347, Berlin, Germany
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22
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Abstract
BACKGROUND There is a known high prevalence of genetic and clinical syndrome diagnoses in the paediatric cardiac population. These disorders often have multisystem effects, which may have an important impact on neurodevelopmental outcomes. Taken together, these facts suggest that patients and families may benefit from consultation by genetic specialists in a cardiac neurodevelopmental clinic. OBJECTIVE This study assessed the burden of genetic disorders and utility of genetics evaluation in a cardiac neurodevelopmental clinic. METHODS A retrospective chart review was conducted of patients evaluated in a cardiac neurodevelopmental clinic from 6 December, 2011 to 16 April, 2013. All patients were seen by a cardiovascular geneticist with genetic counselling support. RESULTS A total of 214 patients were included in this study; 64 of these patients had a pre-existing genetic or syndromic diagnosis. Following genetics evaluation, an additional 19 were given a new clinical or laboratory-confirmed genetic diagnosis including environmental such as teratogenic exposures, malformation associations, chromosomal disorders, and single-gene disorders. Genetic testing was recommended for 112 patients; radiological imaging to screen for congenital anomalies for 17 patients; subspecialist medical referrals for 73 patients; and non-genetic clinical laboratory testing for 14 patients. Syndrome-specific guidelines were available and followed for 25 patients with known diagnosis. American Academy of Pediatrics Red Book asplenia guideline recommendations were given for five heterotaxy patients, and family-based cardiac screening was recommended for 23 families affected by left ventricular outflow tract obstruction. CONCLUSION Genetics involvement in a cardiac neurodevelopmental clinic is helpful in identifying new unifying diagnoses and providing syndrome-specific care, which may impact the patient's overall health status and neurodevelopmental outcome.
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23
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Fogel MA, Li C, Elci OU, Pawlowski T, Schwab PJ, Wilson F, Nicolson SC, Montenegro LM, Diaz L, Spray TL, Gaynor JW, Fuller S, Mascio C, Keller MS, Harris MA, Whitehead KK, Bethel J, Vossough A, Licht DJ. Neurological Injury and Cerebral Blood Flow in Single Ventricles Throughout Staged Surgical Reconstruction. Circulation 2016; 135:671-682. [PMID: 28031423 DOI: 10.1161/circulationaha.116.021724] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 12/12/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with a single ventricle experience a high rate of brain injury and adverse neurodevelopmental outcome; however, the incidence of brain abnormalities throughout surgical reconstruction and their relationship with cerebral blood flow, oxygen delivery, and carbon dioxide reactivity remain unknown. METHODS Patients with a single ventricle were studied with magnetic resonance imaging scans immediately prior to bidirectional Glenn (pre-BDG), before Fontan (BDG), and then 3 to 9 months after Fontan reconstruction. RESULTS One hundred sixty-eight consecutive subjects recruited into the project underwent 235 scans: 63 pre-BDG (mean age, 4.8±1.7 months), 118 BDG (2.9±1.4 years), and 54 after Fontan (2.4±1.0 years). Nonacute ischemic white matter changes on T2-weighted imaging, focal tissue loss, and ventriculomegaly were all more commonly detected in BDG and Fontan compared with pre-BDG patients (P<0.05). BDG patients had significantly higher cerebral blood flow than did Fontan patients. The odds of discovering brain injury with adjustment for surgical stage as well as ≥2 coexisting lesions within a patient decreased (63%-75% and 44%, respectively) with increasing amount of cerebral blood flow (P<0.05). In general, there was no association of oxygen delivery (except for ventriculomegaly in the BDG group) or carbon dioxide reactivity with neurological injury. CONCLUSIONS Significant brain abnormalities are commonly present in patients with a single ventricle, and detection of these lesions increases as children progress through staged surgical reconstruction, with multiple coexisting lesions more common earlier than later. In addition, this study demonstrated that BDG patients had greater cerebral blood flow than did Fontan patients and that an inverse association exists of various indexes of cerebral blood flow with these brain lesions. However, CO2 reactivity and oxygen delivery (with 1 exception) were not associated with brain lesion development. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02135081.
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Affiliation(s)
- Mark A Fogel
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.).
| | - Christine Li
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Okan U Elci
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Tom Pawlowski
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Peter J Schwab
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Felice Wilson
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Susan C Nicolson
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Lisa M Montenegro
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Laura Diaz
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Thomas L Spray
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - J William Gaynor
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Stephanie Fuller
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Christopher Mascio
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Marc S Keller
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Matthew A Harris
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Kevin K Whitehead
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Jim Bethel
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Arastoo Vossough
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
| | - Daniel J Licht
- From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.)
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24
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LaRovere KL, O'Brien NF. Transcranial Doppler Sonography in Pediatric Neurocritical Care: A Review of Clinical Applications and Case Illustrations in the Pediatric Intensive Care Unit. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:2121-32. [PMID: 26573100 DOI: 10.7863/ultra.15.02016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 03/31/2015] [Indexed: 05/25/2023]
Abstract
Transcranial Doppler sonography is a noninvasive, real-time physiologic monitor that can detect altered cerebral hemodynamics during catastrophic brain injury. Recent data suggest that transcranial Doppler sonography may provide important information about cerebrovascular hemodynamics in children with traumatic brain injury, intracranial hypertension, vasospasm, stroke, cerebrovascular disorders, central nervous system infections, and brain death. Information derived from transcranial Doppler sonography in these disorders may elucidate underlying pathophysiologic characteristics, predict outcomes, monitor responses to treatment, and prompt a change in management. We review emerging applications for transcranial Doppler sonography in the pediatric intensive care unit with case illustrations from our own experience.
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Affiliation(s)
- Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts USA (K.L.L.); and Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital and Ohio State University, Columbus, Ohio USA (N.F.O.).
| | - Nicole F O'Brien
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts USA (K.L.L.); and Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital and Ohio State University, Columbus, Ohio USA (N.F.O.)
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25
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Fogel MA, Li C, Wilson F, Pawlowski T, Nicolson SC, Montenegro LM, Diaz Berenstein L, Spray TL, Gaynor JW, Fuller S, Keller MS, Harris MA, Whitehead KK, Clancy R, Elci O, Bethel J, Vossough A, Licht DJ. Relationship of cerebral blood flow to aortic-to-pulmonary collateral/shunt flow in single ventricles. Heart 2015; 101:1325-31. [PMID: 26048877 DOI: 10.1136/heartjnl-2014-307311] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 05/11/2015] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Patients with single ventricle can develop aortic-to-pulmonary collaterals (APCs). Along with systemic-to-pulmonary artery shunts, these structures represent a direct pathway from systemic to pulmonary circulations, and may limit cerebral blood flow (CBF). This study investigated the relationship between CBF and APC flow on room air and in hypercarbia, which increases CBF in patients with single ventricle. METHODS 106 consecutive patients with single ventricle underwent 118 cardiac magnetic resonance (CMR) scans in this cross-sectional study; 34 prior to bidirectional Glenn (BDG) (0.50±0.30 years old), 50 prior to Fontan (3.19±1.03 years old) and 34 3-9 months after Fontan (3.98±1.39 years old). Velocity mapping measured flows in the aorta, cavae and jugular veins. Analysis of variance (ANOVA) and multiple linear regression were used. Significance was p<0.05. RESULTS A strong inverse correlation was noted between CBF and APC/shunt both on room air and with hypercarbia whether CBF was indexed to aortic flow or body surface area, independent of age, cardiopulmonary bypass time, Po2 and Pco2 (R=-0.67--0.70 for all patients on room air, p<0.01 and R=-0.49--0.90 in hypercarbia, p<0.01). Correlations were not different between surgical stages. CBF was lower, and APCs/shunt flow was higher prior to BDG than in other stages. CONCLUSIONS There is a strong inverse relationship between CBF and APC/shunt flow in patients with single ventricle throughout surgical reconstruction on room air and in hypercarbia independent of other factors. We speculate that APC/shunt flow may have a negative impact on cerebral development and neurodevelopmental outcome. Interventions on APC may modify CBF, holding out the prospect for improving neurodevelopmental trajectory. TRIAL REGISTRATION NUMBER NCT02135081.
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Affiliation(s)
- Mark A Fogel
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christine Li
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Felice Wilson
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tom Pawlowski
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa M Montenegro
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laura Diaz Berenstein
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marc S Keller
- Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew A Harris
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin K Whitehead
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Clancy
- Department of Neurology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Arastoo Vossough
- Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel J Licht
- Department of Neurology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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