Factors associated with survival in patients who undergo peritoneal dialysis catheter placement following cardiac surgery

The salutary effect of peritoneal dialysis catheters on enhanced recovery among high-risk pediatric patients undergoing the left coronary transfer procedure: a cohort study

BACKGROUND

Evidence for peritoneal dialysis catheter (PDC) usage in pediatric patients undergoing surgery for deteriorating cardiac dysfunction is lacking. This investigation explored factors associated with PDC usage and its effectiveness in children with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).

METHODS

Eighty-four children undergoing left coronary artery transfer were retrospectively recruited. The primary endpoint was the postoperative ratio of the general ward/[intensive care unit (ICU)] length of stay. Univariable and multivariable analyses were fitted to assess factors related most strongly to PDC and the ratio of general ward/ICU length of stay.

RESULTS

Of the 84 patients, 17 (20.2%) underwent postoperative PDC placement. Patients with extreme cardiac dysfunction [left ventricular ejection fraction (LVEF) ≤25%] were much more likely to require a PDC (OR, 9.88; 95% CI, 2.13-45.76; P = 0.003). Moreover, univariate analysis indicated that concomitant mitral repair significantly decreased the likelihood of PDC placement (OR, 0.25; 95% CI, 0.07-0.85; P = 0.026). In those with cardiac dysfunction (LVEF ≤50%), PDC use was associated with a reduced ratio of ward/ICU length of stay (B, - 1.62; 95% CI, - 2.77- -0.46; P = 0.008), as was age ≤ 12 months (B, - 1.57; 95% CI, - 2.88- -0.26; P = 0.02). At the 1-year follow-up, cardiac improvement was significantly greater in patients with PDC usage than in those without it (P <  0.001), and the number of mitral recoveries was comparable between the groups (64.2% vs. 53.3%, P = 0.434).

CONCLUSION

In cohorts with ALCAPA, PDC placement following surgery may be necessary for patients with extreme cardiac compromise, while concomitant mitral repair can probably reduce their usage rate. PDC is beneficial in conferring an improvement in cardiac and mitral performance. Importantly, after patients are transferred from the ICU, recovery efficiency in the general ward can be enhanced by PDC placement, and hospital discharge can therefore be achieved early, especially for patients younger than 12 months or with LVEF ≤50%.

Peritoneal dialysis during congenital heart surgery admissions: insights from a large database

BACKGROUND

The management of fluid overload after congenital heart surgery has been limited to diuretics, fluid restriction, and dialysis. This study was conducted to determine the association between peritoneal dialysis and important clinical outcomes in children undergoing congenital heart surgery.

METHODS

A retrospective review was conducted to identify patients under 18 years of age who underwent congenital heart surgery. The data were obtained over a 16-year period (1997-2012) from the Kids' Inpatient Database. Data analysed consisted of demographics, diagnoses, type of congenital heart surgery, length of stay, cost of hospitalisation, and mortality. Logistic regression was performed to determine factors associated with peritoneal dialysis.

RESULTS

A total of 46,176 admissions after congenital heart surgery were included in the study. Of those, 181 (0.4%) utilised peritoneal dialysis. The mean age of the peritoneal dialysis group was 7.6 months compared to 39.6 months in those without peritoneal dialysis. The most common CHDs were atrial septal defect (37%), ventricular septal defect (32.6%), and hypoplastic left heart syndrome (18.8%). Univariate analyses demonstrated significantly greater length of stay, cost of admission, and mortality in those with peritoneal dialysis. Regression analyses demonstrated that peritoneal dialysis was independently associated with significant decrease in cost of admission (-$57,500) and significant increase in mortality (odds ratio 1.5).

CONCLUSIONS

Peritoneal dialysis appears to be used in specific patient subsets and is independently associated with decreased cost of stay, although it is associated with increased mortality. Further studies are needed to describe risks and benefit of peritoneal dialysis in this population.

Fluid Management With Peritoneal Dialysis After Pediatric Cardiac Surgery

Children who undergo cardiac surgery with cardiopulmonary bypass are a unique population at high risk for postoperative acute kidney injury (AKI) and fluid overload. Fluid management is important in the postoperative care of these children as fluid overload is associated with increased morbidity and mortality. Peritoneal dialysis catheters are an important tool in the armamentarium of a cardiac intensivist and are used for passive drainage for fluid removal or dialysis for electrolyte and uremia control in AKI. Prophylactic placement of a peritoneal catheter is a safe method of fluid removal that is associated with few major complications. Early initiation of peritoneal dialysis has been associated with improved clinical markers and outcomes such as early achievement of a negative fluid balance, lower vasoactive medication needs, shorter duration of mechanical ventilation, and decreased mortality. In this review, we discuss the safety and potential benefits of peritoneal catheters for dialysis or passive drainage in children following cardiopulmonary bypass.

Acute kidney injury and fluid overload in infants and children after cardiac surgery

Acute kidney injury is a common and serious complication after congenital heart surgery, particularly among infants. This comorbidity has been independently associated with adverse outcomes including an increase in mortality. Postoperative acute kidney injury has a complex pathophysiology with many risk factors, and therefore no single medication or therapy has been demonstrated to be effective for treatment or prevention. However, it has been established that the associated fluid overload is one of the major determinants of morbidity, particularly in infants after cardiac surgery. Therefore, in the absence of an intervention to prevent acute kidney injury, much of the effort to improve outcomes has focused on treating and preventing fluid overload. Early renal replacement therapy, often in the form of peritoneal dialysis, has been shown to be safe and beneficial in infants with oliguria after heart surgery. As understanding of the pathophysiology of acute kidney injury and the ability to confidently diagnose it earlier continues to evolve, it is likely that novel preventative and therapeutic interventions will be available in the future.

Safety of peritoneal and pleural drain placement in pediatric stem cell transplant recipients with severe veno-occlusive disease

Hepatic VOD (veno-occlusive disease) is a serious complication of HSCT (hematopoietic stem cell transplantation) and has historically been associated with high mortality. This obstruction to hepatic flow often results in fluid collections in the peritoneal and pleural cavities. Catheter placement to drain ascites or pleural fluid may reduce intra-abdominal hypertension and/or improve respiratory parameters. The safety of these interventions among critically ill, immunocompromised children is unknown. Among 32 HSCT recipients (2000-2012) with severe VOD, we assessed the primary outcome of procedural complication from peritoneal drain placement. Twenty-four (75%) patients underwent peritoneal drain placement. No patient sustained visceral perforation or hemorrhage with drain placement. Overall mortality was 47% (n = 15). The procedure was not associated with increased overall mortality (p > 0.99). Eight (25%) peritoneal drains required replacement for malfunction. Of 24 patients with peritoneal drains, one (4%) patient had a positive culture from ascitic fluid. Eight (25%) patients underwent pleural drain placement. No pleural drain-related procedural complication or infection occurred. Four (50%) of the eight patients with pleural drains had de-escalation in oxygen requirement at drain removal, compared to time of placement. In this study, peritoneal and pleural drains were safe interventions for children with severe VOD.

Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Fluid Management

OBJECTIVE

In this Consensus Statement, we review the etiology and pathophysiology of fluid disturbances in critically ill children with cardiac disease. Clinical tools used to recognize pathologic fluid states are summarized, as are the mechanisms of action of many drugs aimed at optimal fluid management.

DATA SOURCES

The expertise of the authors and a review of the medical literature were used as data sources.

DATA SYNTHESIS

The authors synthesized the data in the literature in order to present clinical tools used to recognize pathologic fluid states. For each drug, the physiologic rationale, mechanism of action, and pharmacokinetics are synthesized, and the evidence in the literature to support the therapy is discussed.

CONCLUSIONS

Fluid management is challenging in critically ill pediatric cardiac patients. A myriad of causes may be contributory, including intrinsic myocardial dysfunction with its associated neuroendocrine response, renal dysfunction with oliguria, and systemic inflammation with resulting endothelial dysfunction. The development of fluid overload has been associated with adverse outcomes, including acute kidney injury, prolonged mechanical ventilation, increased vasoactive support, prolonged hospital length of stay, and mortality. An in-depth understanding of the many factors that influence volume status is necessary to guide optimal management.