Fluid Status Assessment and Management During the Perioperative Phase in Pediatric Cardiac Surgery Patients

Respiratory variation in the internal jugular vein does not predict fluid responsiveness in the prone position during adolescent idiopathic scoliosis surgery: a prospective cohort study

BACKGROUND

Respiratory variation in the internal jugular vein (IJVV) has not shown promising results in predicting volume responsiveness in ventilated patients with low tidal volume (Vt) in prone position. We aimed to determine whether the baseline respiratory variation in the IJVV value measured by ultrasound might predict fluid responsiveness in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with low Vt.

METHODS

According to the fluid responsiveness results, the included patients were divided into two groups: those who responded to volume expansion, denoted the responder group, and those who did not respond, denoted the non-responder group. The primary outcome was determination of the value of baseline IJVV in predicting fluid responsiveness (≥15% increases in stroke volume index (SVI) after 7 ml·kg-1 colloid administration) in patients with AIS undergoing PSF during low Vt ventilation. Secondary outcomes were estimation of the diagnostic performance of pulse pressure variation (PPV), stroke volume variation (SVV), and the combination of IJVV and PPV in predicting fluid responsiveness in this surgical setting. The ability of each parameter to predict fluid responsiveness was assessed using a receiver operating characteristic curve.

RESULTS

Fifty-six patients were included, 36 (64.29%) of whom were deemed fluid responsive. No significant difference in baseline IJVV was found between responders and non-responders (25.89% vs. 23.66%, p = 0.73), and no correlation was detected between baseline IJVV and the increase in SVI after volume expansion (r = 0.14, p = 0.40). A baseline IJVV greater than 32.00%, SVV greater than 14.30%, PPV greater than 11.00%, and a combination of IJVV and PPV greater than 64.00% had utility in identifying fluid responsiveness, with a sensitivity of 33.33%, 77.78%, 55.56%, and 55.56%, respectively, and a specificity of 80.00%, 50.00%, 65.00%, and 65.00%, respectively. The area under the receiver operating characteristic curve for the baseline values of IJVV, SVV, PPV, and the combination of IJVV and PPV was 0.52 (95% CI, 0.38-0.65, p=0.83), 0.54 (95% CI, 0.40-0.67, p=0.67), 0.58 (95% CI, 0.45-0.71, p=0.31), and 0.57 (95% CI, 0.43-0.71, p=0.37), respectively.

CONCLUSIONS

Ultrasonic-derived IJVV lacked accuracy in predicting fluid responsiveness in patients with AIS undergoing PSF during low Vt ventilation. In addition, the baseline values of PPV, SVV, and the combination of IJVV and PPV did not predict fluid responsiveness in this surgical setting.

TRAIL REGISTRATION

This trial was registered at www.chictr.org (ChiCTR2200064947) on 24/10/2022. All data were collected through chart review.

Fluid balance in pediatric critically ill patients (with and without kidney dysfunction)

PURPOSE OF REVIEW

The issues of fluid balance and fluid overload are currently considered crucial aspects of pediatric critically ill patients' care.

RECENT FINDINGS

This review describes current understanding of fluid management in critically ill children in terms of fluid balance and fluid overload and its effects on patients' outcomes. The review describes current evidence surrounding definitions, monitoring, and treatment of positive fluid balance. In particular, the review focuses on specific patient conditions, including perioperative cardiac surgery, severe acute respiratory failure, and extracorporeal membrane oxygenation therapy, as the ones at highest risk of developing fluid overload and poor clinical outcomes. Gaps in understanding include specific thresholds at which fluid overload occurs in all critically ill children or specific populations and optimal timing of decongestion of positive fluid balance.

SUMMARY

Current evidence on fluid balance in critically ill children is mainly based on retrospective and observational studies, and intense research should be recommended in this important field. In theory, active decongestion of patients with fluid overload could improve mortality and other clinical outcomes, but randomized trials or advanced pragmatic studies are needed to better understand the optimal timing, patient characteristics, and tools to achieve this.

Diagnostic Utility of Point-of-Care Ultrasound in the Pediatric Cardiac Intensive Care Unit

Purpose of Review

Recent Findings

Summary

Supplementary Information

Documenting urine output for pediatric urology patients in the post-anesthesia care unit: A quality improvement initiative

INTRODUCTION

Close monitoring and documentation of urine output (UOP) after urologic surgery is a nursing standard of care in the post-anesthesia care unit (PACU). UOP is a critical piece of information for surgeons and anesthesiologists to provide safe quality patient care. The electronic medical record (EMR) is used to communicate this information between members of the care team. Initial review at our institution confirmed only 31.3% of children recovering in the PACU after urologic surgery had a numerical value for UOP documented in the EMR.

OBJECTIVE

The aim of this project was to improve compliance of UOP documentation in the EMR for pediatric urologic patients in the PACU from 31.3% to 80% by August 2021, using quality improvement methodology.

STUDY DESIGN

Patients undergoing urologic surgery with planned post-operative hospital admission were identified in the EMR by admission status and Current Procedural Terminology (CPT) code. UOP documentation data during the patients' PACU stay was retrieved from the EMR. Traditional QI methods were used to develop a key driver diagram, identify barriers, and implement targeted interventions. Statistical process control charts tracked the outcome measure (percentage of patients with UOP documented in the PACU) and balancing measure (average PACU length of stay).

RESULTS

The project began in July 2019, and four interventions started between July and October 2019. These interventions resulted in a centerline shift of our outcome measure, UOP documentation rate, from 31.3% to 76.2% (p < 0.001). Patient volumes were stable with the exception of March, April, and May 2020 during the Covid-19 pandemic. An X-bar chart tracked PACU LOS, the balancing measure, in average minutes per patient without any trends.

DISCUSSION

This quality improvement initiative sought to improve urine output (UOP) documentation for pediatric urologic patients during the immediate post-operative period. Targeted interventions leading to this improvement included educating nursing staff, establishing direct communication expectations for the surgical team, and improving the availability of UOP measurement tools. Limitations include reliance on education and behavioral change, only including urologic surgery patients, and our institution's robust focus on quality improvement work.

CONCLUSIONS

This performance improvement initiative successfully increased the rate of UOP documentation by PACU nurses for pediatric urology patients through a combination of interventions. The next phase is to expand these interventions throughout the hospital to improve UOP documentation for all post-operative patients.

Administration of fibrinogen concentrate combined with prothrombin complex maintains hemostasis in children undergoing congenital heart repair (a long-term propensity score-matched study)

Background

Bleeding is a common problem in children with congenital heart disease undergoing major cardiac surgery requiring cardiopulmonary bypass (CPB). Little is known about optimal management with blood products.

Objective

To investigate clinical outcome and hemostatic effects of fibrinogen concentrate (FC) in combination with prothrombin complex concentrate (PCC) versus standard treatment with fresh frozen plasma (FFP) in children undergoing cardiac surgery.

Methods

For this single‐institution cohort study, data on 525 children were analyzed. Propensity score matching in 210 children was applied to reduce the impact of various baseline characteristics.

Results

Three children treated with FC/PCC developed surgical site bleeding requiring surgical revision. One child developed central venous line‐related thrombosis. Blood loss through chest tube drainage was independent of FC/PCC. Coagulation abnormalities were not present in any of these children. Time to extubation and ICU stay did not differ. In the FC/PCC group, children received (median, Q1, Q3) 52 mg/kg (32, 83) FC and 28IU/kg (13, 44) PCC. Fibrinogen concentration was comparable at baseline. On admission to the ICU, fibrinogen was higher in children receiving FC/PCC, namely, 232 mg/dL (196, 280), than in children receiving FFP (186 mg/dL, 149, 224; P < .001). On discharge from the ICU, values did not differ ((FC/PCC 416 mg/dL (288, 501)), non‐FC/PCC 418 mg/dL (272, 585; P = 1.000)).

Conclusion

FC/PCC was well tolerated and permitted hemostasis to be maintained, even in the very young. We were not able to detect a signal for inferiority of this treatment. We conclude that FC/PCC can safely replace FFP.

Diagnostic accuracy of stroke volume variation for predicting fluid responsiveness in children undergoing cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Stroke volume variation appears to be reliable for predicting fluid responsiveness in adults, and its predictive value in pediatric patients has been recently reported. However, its predictive value in children undergoing cardiac surgery is unclear.

METHODS

A review and meta-analysis were performed on the diagnostic utility of stroke volume variation for predicting fluid responsiveness in children undergoing cardiac surgery. All relevant articles for prospective research assessing the value of stroke volume variation were searched in the Embase, MEDLINE (PubMed), and Cochrane databases through March 2020. The primary outcome was the accuracy of stroke volume variation for predicting fluid responsiveness in children. The combined data were analyzed by a meta-analysis. Publication quality was assessed using the QUADAS (quality assessment for studies of diagnostic accuracy, maximum score) standard guidelines.

RESULTS

Six articles were included in the meta-analysis, following the search strategy. A total of 251 children were included from 6 prospective studies. Fluid therapy for all patients used crystalloids or colloids. The results of the analysis revealed a pooled diagnostic odds ratio of 8.23 (95% CI: 3.07-22.11), pooled sensitivity of 0.73 (95% CI: 0.64-0.80), and pooled specificity of 0.66 (95% CI: 0.58-0.74). Additionally, the overall area of the summary receiver operating characteristic curve was 0.78. There was significant moderate heterogeneity in these studies (p < .05, I²  = 42.1%) due to thresholds.

CONCLUSIONS

There was some heterogeneity due to thresholds in the included studies. An evaluation of stroke volume variation may represent a reliable predictor of fluid responsiveness in children undergoing cardiac surgery. After operative cardiac output optimization, the possible impact of goal-directed fluid treatment depending on stroke volume variation on the perioperative outcome in the children population should subsequently be assessed.

The clinical value of passive leg raising plus ultrasound to predict fluid responsiveness in children after cardiac surgery

Background

There are few non-invasive monitoring methods that can reliably predict fluid responsiveness (FR) in children. Here, we interrogate the value of doppler ultrasound evaluation of passive leg raising (PLR)-induced changes in stroke volume (SV) and cardiac output (CO) as a predictor of FR in children with mechanical ventilation after congenital cardiac surgery.

Methods

A total of 40 children with mechanical ventilation following congenital cardiac surgery, who required volume expansion (VE) were included in this study. Hemodynamic parameters such as heart rate (HR), mean arterial pressure (MAP), SV, and central venous pressure (CVP) were monitored before and after PLR and VE. Besides, we assessed changes in SV and CO by bedside ultrasound. Patients showing > 10 % increase in SV in response to VE were considered to be responders (26 patients), while the rest (14 patients) were defined as non-responders.

Results

Our data demonstrated that ΔSV-PLR and ΔCO- PLR were positively correlated with ΔSV-VE (r = 0.683, p < 0.001 and r = 0.374, p = 0.017, respectively), and the area under the ROC curve (AUC) of ΔSV-PLR was 0.879 (95 % CI [0.745 1.000], p < 0.001). The best cut-off value for ΔSV-PLR in predicting FR was 13 %, with its sensitivity and specificity were 81.8 and 86.3 %, respectively. ΔCVP, ΔHR, and ΔMAP were weak predictors of FR in the children.

Conclusions

Our study demonstrated that SV changes, as evaluated by noninvasive ultrasound combined with PLR, could effectively evaluate FR in children under mechanical ventilation after congenital cardiac surgery.

Validation of Point-of-Care Ultrasound to Measure Perioperative Edema in Infants With Congenital Heart Disease

Purpose: Fluid overload is a common post-operative issue in children following cardiac surgery and is associated with increased morbidity and mortality. There is currently no gold standard for evaluating fluid status. We sought to validate the use of point-of-care ultrasound to measure skin edema in infants and assess the intra- and inter-user variability. Methods: Prospective cohort study of neonates (≤30 d/o) and infants (31 d/o to 12 m/o) undergoing cardiac surgery and neonatal controls. Skin ultrasound was performed on four body sites at baseline and daily post-operatively through post-operative day (POD) 3. Subcutaneous tissue depth was manually measured. Intra- and inter-user variability was assessed using intraclass correlation coefficient (ICC). Results: Fifty control and 22 surgical subjects underwent skin ultrasound. There was no difference between baseline surgical and control neonates. Subcutaneous tissue increased in neonates starting POD 1 with minimal improvement by POD 3. In infants, this pattern was less pronounced with near resolution by POD 3. Intra-user variability was excellent (ICC 0.95). Inter-user variability was very good (ICC 0.82). Conclusion: Point-of-care skin ultrasound is a reproducible and reliable method to measure subcutaneous tissue in infants with and without congenital heart disease. Acute increases in subcutaneous tissue suggests development of skin edema, consistent with extravascular fluid overload. There is evidence of skin edema starting POD 1 in all subjects with no substantial improvement by POD 3 in neonates. Point-of-care ultrasound could be an objective way to measure extravascular fluid overload in infants. Further research is needed to determine how extravascular fluid overload correlates to clinical outcomes.

Goal-directed perfusion to reduce acute kidney injury after paediatric cardiac surgery (GDP-AKIp): study protocol for a prospective randomised controlled trial

INTRODUCTION

Cardiac surgery-associated acute kidney injury (CS-AKI) occurs in up to 40%~60% of paediatric patients and increases postoperative morbidity and mortality. A goal-directed perfusion (GDP) strategy aimed at maintaining indexed oxygen delivery (DO₂i) above the critical threshold (reported to be 260~300 mL/min/m² in adults) during cardiopulmonary bypass (CPB), is effective in reducing the incidence of CS-AKI. However, no clear standards of paediatric critical DO₂i exist. Our prior prospective cohort study exploring the critical DO₂i threshold during paediatric CPB has found the nadir DO₂i <353 mL/min/m² was an independent risk predictor of CS-AKI. Based on this background, this trial is designed to further determine whether the implementation of the GDP initiative aimed at maintaining DO₂i ≥360 mL/min/m² would reduce the rate of CS-AKI in paediatrics and improve clinical outcome.

METHODS AND ANALYSIS

This is a prospective, single-centre, randomised controlled trial. In total, 166 paediatric patients undergoing cardiac surgery will be randomly allocated to the GDP group or control group. Patients in the GDP arm will be treated with a GDP strategy during CPB aimed to maintain DO₂i at ≥360 mL/min/m² (to ensure safely above the risk DO₂i threshold we found). The perfusion strategy for patients in the control arm will be factored on body surface area and temperature. The primary outcome is the rate of postoperative CS-AKI (it is defined according to paediatric Risk, Injury, Failure, Loss of renal function and End-stage renal disease criteria). The secondary end points include: (1) the other oxygen metabolism parameters during CPB; (2) major complication and all-cause mortality (in-hospital or within 30 days postoperatively); (3) short-term clinical outcomes (ie, time to extubation, mechanical ventilation time, hospital stay).

ETHICS AND DISSEMINATION

The study has been approved by the Biomedical Research Ethics committee of West China Hospital of Sichuan University (approval number: 2019(863)). Results will be disseminated through peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2000029232.

Association of postoperative fluid overload with adverse outcomes after congenital heart surgery: a systematic review and dose-response meta-analysis

BACKGROUND

Pediatric cardiac surgery is commonly associated with acute kidney injury (AKI) and significant fluid retention, which complicate postoperative management and lead to increased rates of morbidity. This meta-analysis aimed to accumulate current literature evidence and evaluate the correlation of fluid overload degree with adverse outcome in patients undergoing congenital heart surgery.

METHODS

Medline, Scopus, CENTRAL, Clinicaltrials.gov, and Google Scholar were systematically searched from inception. All studies reporting the effects of fluid overload on postoperative clinical outcomes were selected. A dose-response meta-analytic method using restricted cubic splines was implemented in R-3.6.1.

RESULTS

Twelve studies were included, with a total of 3111 pediatric patients. Qualitative synthesis indicated that fluid overload was linked to significantly higher risk of mortality, AKI, prolonged hospital, and intensive care unit (ICU) stay, as well as with increased duration of mechanical ventilation, inotrope need, and infection rate. Meta-analysis demonstrated a linear correlation between fluid overload and the risk of mortality (χ² = 6.22, p value = 0.01) and AKI (χ² = 35.84, p value < 0.001), while a positive curvilinear relationship was estimated for the outcomes of hospital (χ² = 18.84, p value = 0.0001) and ICU stay (χ² = 63.69, p value = 0.0001).

CONCLUSIONS

The present meta-analysis supports that postoperative fluid overload is significantly linked to elevated risk of prolonged hospital stay, AKI development, and mortality in pediatric patients undergoing cardiac surgery. These findings warrant replication by future prospective studies, which should define the optimal cutoff values and assess the effectiveness of therapeutic strategies to limit fluid overload in the postoperative setting.

Trends and Updates on Cardiopulmonary Bypass Setup in Pediatric Cardiac Surgery

Perfusion strategies for cardiopulmonary bypass have direct consequences on pediatric cardiac surgery outcomes. However, inconsistent study results and a lack of uniform evidence-based guidelines for pediatric cardiopulmonary bypass management have led to considerable variability in perfusion practices among, and even within, institutions. Important aspects of cardiopulmonary bypass that can be optimized to improve clinical outcomes of pediatric patients undergoing cardiac surgery include extracorporeal circuit components, priming solutions, and additives. This review summarizes the current literature on circuit components and priming solution composition with an emphasis on crystalloid, colloid, and blood-based primes, as well as mannitol, bicarbonate, and calcium.

Pulse waveform hemodynamic monitoring devices: recent advances and the place in goal-directed therapy in cardiac surgical patients

Hemodynamic monitoring has evolved and improved greatly during the past decades as the medical approach has shifted from a static to a functional approach. The technological advances have led to innovating calibrated or not, but minimally invasive and noninvasive devices based on arterial pressure waveform (APW) analysis. This systematic clinical review outlines the physiologic rationale behind these recent technologies. We describe the strengths and the limitations of each method in terms of accuracy and precision of measuring the flow parameters (stroke volume, cardiac output) and dynamic parameters which predict the fluid responsiveness. We also analyzed the place of the APW monitoring devices in goal-directed therapy (GDT) protocols in cardiac surgical patients. According to the data from the three GDT-randomized control trials performed in cardiac surgery (using two types of APW techniques PiCCO and FloTrac/Vigileo), these devices did not demonstrate that they played a role in decreasing mortality, but only decreasing the ventilation time and the ICU and hospital length of stay.