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Saito J, Ichikawa S, Kudo R, Saito K, Kiyokawa M, Kushikata T. Usefulness of bilateral cerebral regional oxygen saturation measurements in determining selective cerebral perfusion flow rate in a pediatric patient with aortic arch stenosis: a case report. JA Clin Rep 2024; 10:57. [PMID: 39298092 DOI: 10.1186/s40981-024-00742-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 08/24/2024] [Accepted: 09/10/2024] [Indexed: 09/21/2024] Open
Abstract
BACKGROUND We report a pediatric case where bilateral regional oxygen saturation (rSO2) measurements were useful in determining the selective cerebral perfusion (SCP) flow rate. CASE PRESENTATION A 9-year-old Japanese boy, 128 cm tall and weighing 25.6 kg, was scheduled for aortic arch reconstruction due to a 90-100 mmHg pressure gradient. Pediatric-sized oximetry sensors were attached to the bilateral forehead area. The rSO2 levels were 70-80% on the right and 80-90% on the left during cardiopulmonary bypass. Immediately following deep hypothermic circulatory arrest with the body temperature cooled to 25 °C, SCP was initiated from the right brachiocephalic artery at 10 mL/kg/min. As the rSO2 decreased steeply to 43-45% on the right and to 32-38% on the left, the SCP flow was increased to 15 mL/kg/min. The right rSO2 increased promptly to 50-60%, but the left rSO2 remained at 30-40%. After the SCP flow was increased to 20 mL/kg/min, bilateral rSO2 levels of 50-60% were obtained, and the SCP flow rate was maintained. The patient was transferred to the ICU postoperatively and extubated on the second postoperative day with no neurological abnormalities. CONCLUSIONS Bilateral rSO2 measurements are essential even for a pediatric patient undergoing SCP, despite the limited forehead area.
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Affiliation(s)
- Junichi Saito
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan.
| | - Shino Ichikawa
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Reiko Kudo
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Kurumi Saito
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Masayo Kiyokawa
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Tetsuya Kushikata
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
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Benson EJ, Aronowitz DI, Forti RM, Lafontant A, Ranieri NR, Starr JP, Melchior RW, Lewis A, Jahnavi J, Breimann J, Yun B, Laurent GH, Lynch JM, White BR, Gaynor JW, Licht DJ, Yodh AG, Kilbaugh TJ, Mavroudis CD, Baker WB, Ko TS. Diffuse Optical Monitoring of Cerebral Hemodynamics and Oxygen Metabolism during and after Cardiopulmonary Bypass: Hematocrit Correction and Neurological Vulnerability. Metabolites 2023; 13:1153. [PMID: 37999249 PMCID: PMC10672802 DOI: 10.3390/metabo13111153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
Cardiopulmonary bypass (CPB) provides cerebral oxygenation and blood flow (CBF) during neonatal congenital heart surgery, but the impacts of CPB on brain oxygen supply and metabolic demands are generally unknown. To elucidate this physiology, we used diffuse correlation spectroscopy and frequency-domain diffuse optical spectroscopy to continuously measure CBF, oxygen extraction fraction (OEF), and oxygen metabolism (CMRO2) in 27 neonatal swine before, during, and up to 24 h after CPB. Concurrently, we sampled cerebral microdialysis biomarkers of metabolic distress (lactate-pyruvate ratio) and injury (glycerol). We applied a novel theoretical approach to correct for hematocrit variation during optical quantification of CBF in vivo. Without correction, a mean (95% CI) +53% (42, 63) increase in hematocrit resulted in a physiologically improbable +58% (27, 90) increase in CMRO2 relative to baseline at CPB initiation; following correction, CMRO2 did not differ from baseline at this timepoint. After CPB initiation, OEF increased but CBF and CMRO2 decreased with CPB time; these temporal trends persisted for 0-8 h following CPB and coincided with a 48% (7, 90) elevation of glycerol. The temporal trends and glycerol elevation resolved by 8-24 h. The hematocrit correction improved quantification of cerebral physiologic trends that precede and coincide with neurological injury following CPB.
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Affiliation(s)
- Emilie J. Benson
- Department of Physics & Astronomy, University of Pennsylvania, Philadelphia, PA 19104, USA; (E.J.B.); (A.G.Y.)
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Danielle I. Aronowitz
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (D.I.A.); (J.W.G.); (C.D.M.)
| | - Rodrigo M. Forti
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Alec Lafontant
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Nicolina R. Ranieri
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Jonathan P. Starr
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (J.P.S.); (T.J.K.)
| | - Richard W. Melchior
- Department of Perfusion Services, Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Alistair Lewis
- Department of Chemistry, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jharna Jahnavi
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Jake Breimann
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Bohyun Yun
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Gerard H. Laurent
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Jennifer M. Lynch
- Division of Cardiothoracic Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Brian R. White
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - J. William Gaynor
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (D.I.A.); (J.W.G.); (C.D.M.)
| | - Daniel J. Licht
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Arjun G. Yodh
- Department of Physics & Astronomy, University of Pennsylvania, Philadelphia, PA 19104, USA; (E.J.B.); (A.G.Y.)
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (J.P.S.); (T.J.K.)
| | - Constantine D. Mavroudis
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (D.I.A.); (J.W.G.); (C.D.M.)
| | - Wesley B. Baker
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Tiffany S. Ko
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (J.P.S.); (T.J.K.)
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Shaw K, Mavroudis CD, Ko TS, Jahnavi J, Jacobwitz M, Ranieri N, Forti RM, Melchior RW, Baker WB, Yodh AG, Licht DJ, Nicolson SC, Lynch JM. The use of novel diffuse optical spectroscopies for improved neuromonitoring during neonatal cardiac surgery requiring antegrade cerebral perfusion. Front Pediatr 2023; 11:1125985. [PMID: 37425272 PMCID: PMC10327557 DOI: 10.3389/fped.2023.1125985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 06/01/2023] [Indexed: 07/11/2023] Open
Abstract
Background Surgical procedures involving the aortic arch present unique challenges to maintaining cerebral perfusion, and optimal neuroprotective strategies to prevent neurological injury during such high-risk procedures are not completely understood. The use of antegrade cerebral perfusion (ACP) has gained favor as a neuroprotective strategy over deep hypothermic circulatory arrest (DHCA) due to the ability to selectively perfuse the brain. Despite this theoretical advantage over DHCA, there has not been conclusive evidence that ACP is superior to DHCA. One potential reason for this is the incomplete understanding of ideal ACP flow rates to prevent both ischemia from underflowing and hyperemia and cerebral edema from overflowing. Critically, there are no continuous, noninvasive measurements of cerebral blood flow (CBF) and cerebral oxygenation (StO2) to guide ACP flow rates and help develop standard clinical practices. The purpose of this study is to demonstrate the feasibility of using noninvasive, diffuse optical spectroscopy measurements of CBF and cerebral oxygenation during the conduct of ACP in human neonates undergoing the Norwood procedure. Methods Four neonates prenatally diagnosed with hypoplastic left heart syndrome (HLHS) or a similar variant underwent the Norwood procedure with continuous intraoperative monitoring of CBF and cerebral oxygen saturation (StO2) using two non-invasive optical techniques, namely diffuse correlation spectroscopy (DCS) and frequency-domain diffuse optical spectroscopy (FD-DOS). Changes in CBF and StO2 due to ACP were calculated by comparing these parameters during a stable 5 min period of ACP to the last 5 min of full-body CPB immediately prior to ACP initiation. Flow rates for ACP were left to the discretion of the surgeon and ranged from 30 to 50 ml/kg/min, and all subjects were cooled to 18°C prior to initiation of ACP. Results During ACP, the continuous optical monitoring demonstrated a median (IQR) percent change in CBF of -43.4% (38.6) and a median (IQR) absolute change in StO2 of -3.6% (12.3) compared to a baseline period during full-body cardiopulmonary bypass (CPB). The four subjects demonstrated varying responses in StO2 due to ACP. ACP flow rates of 30 and 40 ml/kg/min (n = 3) were associated with decreased CBF during ACP compared to full-body CPB. Conversely, one subject with a higher flow6Di rate of 50 ml/kg/min demonstrated increased CBF and StO2 during ACP. Conclusions This feasibility study demonstrates that novel diffuse optical technologies can be utilized for improved neuromonitoring in neonates undergoing cardiac surgery where ACP is utilized. Future studies are needed to correlate these findings with neurological outcomes to inform best practices during ACP in these high-risk neonates.
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Affiliation(s)
- Kalil Shaw
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Constantine D. Mavroudis
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Tiffany S. Ko
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jharna Jahnavi
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Marin Jacobwitz
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Nicolina Ranieri
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Rodrigo M. Forti
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Richard W. Melchior
- Department of Perfusion Services, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Wesley B. Baker
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Arjun G. Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, United States
| | - Daniel J. Licht
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Susan C. Nicolson
- Division of Cardiothoracic Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jennifer M. Lynch
- Division of Cardiothoracic Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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Finnigan LEM, Lotto R, Jones H, Lotto A. Cerebral blood flow velocity and oxygenation in neonatal aortic arch repair at two perfusion temperatures. Eur J Cardiothorac Surg 2023; 63:ezad220. [PMID: 37280071 PMCID: PMC10824556 DOI: 10.1093/ejcts/ezad220] [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: 12/15/2022] [Revised: 05/10/2023] [Accepted: 06/05/2023] [Indexed: 06/08/2023] Open
Abstract
OBJECTIVES (i) To monitor cerebral blood flow velocity (CBFv) throughout aortic arch repair surgery and during the recovery period. (ii) To examine the relationship between transcranial doppler ultrasound (TCD) and near-infrared spectroscopy (NIRS) during cardiac surgery. (iii) To examine CBFv in patients cooled to 20°C and 25°C. METHODS During aortic arch repair and after surgery, measurements of TCD, NIRS, blood pH, pO2, pCO2, HCO3, lactate, Hb, haematocrit (%) and temperature (core and rectal) were recorded in 24 neonates. General linear mixed models were used to examine differences over time and between two cooling temperatures. Repeated measures correlations were used to determine the relationship between TCD and NIRS. RESULTS CBFv changed during arch repair (main effect of time: P = 0.001). During cooling, CBFv increased by 10.0 cm/s (5.97, 17.7) compared to normothermia (P = 0.019). Once recovering in paediatric intensive care unit (PICU), CBFv had increased from the preoperative measurement by 6.2 cm/s (0.21, 13.4; P = 0.045). CBFv changes were similar between patients cooled to 20°C and 25°C (main effect of temperature: P = 0.22). Repeated measures correlations (rmcorr) identified a statistically significant but weak positive correlation between CBFv and NIRS (r = 0.25, P≤0.001). CONCLUSIONS Our data suggested that CBFv changed throughout aortic arch repair and was higher during the cooling period. A weak relationship was found between NIRS and TCD. Overall, these findings could provide clinicians with information on how to optimise long-term cerebrovascular health.
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Affiliation(s)
- Lucy E M Finnigan
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Robyn Lotto
- Allied Health and Nursing, Liverpool John Moores University, Liverpool, UK
| | - Helen Jones
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Attilio Lotto
- Heart Centre, Alder Hey Children’s NHS Foundation, Liverpool, UK
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Doctor P, Aggarwal S, Garcia R. Is there an association of near-infrared spectroscopy with low cardiac output and adverse outcomes in single-ventricle patients after stage 1 palliation? Ann Pediatr Cardiol 2022; 15:249-256. [PMID: 36589644 PMCID: PMC9802614 DOI: 10.4103/apc.apc_234_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/22/2022] [Accepted: 06/08/2022] [Indexed: 11/17/2022] Open
Abstract
Objective Our primary objective study was to evaluate the association between near-infrared spectroscopy (NIRS) and low cardiac output (LCO) in patients with single-ventricle physiology after stage 1 palliation. Methods In this retrospective study, infants ≤6 months of age with single-ventricle physiology who underwent stage 1 palliation were included. Cerebral and renal NIRS values at various time intervals after surgery were compared between patients with low and normal cardiac output. LCO within the first 48 after surgery was defined as per the pediatric cardiac critical care consortium database. NIRS values were also compared with other adverse outcomes such as cardiac arrest, need for extracorporeal membrane oxygenation and mortality. The receiver operative characteristic curve was generated to determine an optimal cut-off NIRS value for detecting LCO. Results Ninety-one patients with median (Interquartile range) age of 10 days (6-26) and weight of 3.3 kg (3-3.5) were included in the study. Cerebral NIRS at 1 h (41.2 vs. 49.5; P = 0.002), 6 h (44 vs. 52.2; P = 0.001), and 12 h (51.8 vs. 56; P = 0.025) was significantly lower in the grouP with LCO compared to no LCO. Cerebral NIRS at 6 h was independently associated with LCO (P = 0.018), and cerebral NIRS at 6 h ≤57% had 91% sensitivity and 72% specificity to detect LCO. Conclusions Cerebral NIRS ≤57% at 6 h after surgery detected LCO after stage 1 palliation in single-ventricle patients. Cerebral or renal NIRS was not associated with adverse outcomes and therefore, may not be useful in predicting adverse outcomes in this population.
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Affiliation(s)
- Pezad Doctor
- Department of Pediatrics, Division of Cardiology, Children's Medical Center, University of Texas Southwestern Medical Center, Medical District, Dallas, Texas, USA
| | - Sanjeev Aggarwal
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Michigan, Central Michigan University College of Medicine, Beaubien Blvd, Detroit, MI, USA
| | - Richard Garcia
- Department of Pediatrics, Division of Critical Care Medicine, Children's Hospital of Michigan, Central Michigan University College of Medicine, Beaubien Blvd, Detroit, MI, USA
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Lahiri S, Qureshi AM, Justino H, Mossad EB. Percutaneous Common Carotid Artery Access for Cardiac Interventions in Infants Does Not Acutely Change Cerebral Perfusion. Pediatr Cardiol 2022; 43:104-109. [PMID: 34363498 DOI: 10.1007/s00246-021-02697-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
Pediatric cardiac interventions via percutaneous common carotid artery (CCA) access have been shown to be safe and effective. However, the impact of placement of a sheath in the carotid artery for interventions on cerebral perfusion is unknown. In this study we used cerebral near-infrared spectroscopy (NIRS) to analyze the effects of percutaneous CCA access for cardiac interventions on cerebral perfusion. This study is a retrospective chart review carried out at a tertiary care center on all pediatric patients who underwent percutaneous cardiac catheterization via carotid artery access from January 2010 to January 2020. All patients who had ipsilateral NIRS recorded on the side of carotid artery access were included. Patients with only partial or no ipsilateral NIRS data were excluded. The primary outcome measure was the change in NIRS upon CCA access; the mean NIRS for 15 min before obtaining access was compared to the mean NIRS during the procedure and to the mean NIRS 15 min after removal of the CCA sheath. We hypothesized that there would be a significant drop in NIRS values on the side of CCA access. There were 48 catheterizations in the study period where percutaneous CCA was accessed. Of those, 21 catheterizations had complete data and were included in the study. 13 (62%) were of males. The median age was 23 days (IQR 7-79). The indications for CCA access were patent ductus arteriosus stent implantation (n = 13; 62%), aortic valvuloplasty (n = 5; 24%), balloon angioplasty of coarctation of aorta (n = 2; 10%), and renal artery angioplasty (n = 1; 4%). In 16 patients (72%), the left common carotid artery was accessed. The median weight of the patients was 3.3 kg (IQR 2.8-2.9). The most common sheath size used was 4F, in 16 patients (72%). The mean NIRS prior to the procedure was 67 ± 15%, during the procedure was 68 ± 20%, and after removal of sheath was 68 ± 21%. Paired t test of cerebral NIRS before, during, and after the procedure showed no significant change with CCA access (P = 0.08). No patient in the series had a documented neurologic deficit following the procedure. Percutaneous CCA access was not associated with a decrease in NIRS on the side of the access during the procedure, suggesting there was no significant acute change in cerebral perfusion with CCA access.
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Affiliation(s)
- Subhrajit Lahiri
- Department of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, E1920, Houston, TX, 77030, USA.
| | - Athar M Qureshi
- Department of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, E1920, Houston, TX, 77030, USA
| | - Henri Justino
- Department of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, E1920, Houston, TX, 77030, USA
| | - Emad B Mossad
- Division of Pediatric Cardiac Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, 77030, USA
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Rüffer A, Knieling F, Cesnjevar R, Regensburger A, Purbojo A, Dittrich S, Münch F, Wölfle J, Jüngert J. Equal cerebral perfusion during extended aortic coarctation repair. Eur J Cardiothorac Surg 2021; 61:299-306. [PMID: 34718510 DOI: 10.1093/ejcts/ezab415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/03/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Aortic coarctation with distal aortic arch hypoplasia can be effectively addressed by coarctation resection with extended end-to-end-anastomosis (REEEA). Particularly, when unilateral cerebral perfusion (UCP) is established by clamping of left-sided supra-aortic vessels, the extent of cerebral blood flow distribution during repair remains undetermined, so far. Transfontanellar contrast-enhanced ultrasound (T-CEUS) can be utilized for real-time visualization and quantitative evaluation of cerebral blood flow. This study quantitatively evaluates cerebral perfusion during REEEA by using intraoperative T-CEUS. METHODS In a prospective study, 9 infants with open fontanelle undergoing REEEA [median age: 13 days (range 1-34) and median weight 3.1 kg (range 2.2-4.4)] were intraoperatively examined with T-CEUS at 3 consecutive time-points: before skin incision, during UCP and after skin suture. A software-based analysis of 11 parameters was used for data evaluation. Absolute and relative blood flow in contralateral hemispheres was measured in side-by-side comparison, and referenced to baseline measurements. RESULTS No side-depend absolute or relative cerebral perfusion differences were found during REEEA, except for an increased relative 'wash-out-rate' (P = 0.0013) in favour of the right hemisphere after surgery. Compared to ipsilateral baseline levels, 'rise time' was transiently increased in right (P = 0.0277) and 'time-to-peak' in both hemispheres (right: P = 0.0403 and left: P = 0.0286), all during UCP. CONCLUSIONS The use of T-CEUS provided evidence for homogenous distribution of contrast agent in both hemispheres during UCP. T-CEUS can be utilized for the postprocedural evaluation of cerebral perfusion during congenital cardiac surgery. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov Unique, Identifier: NCT03215628.
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Affiliation(s)
- André Rüffer
- Department for Congenital Cardiac Surgery, University Hospital Aachen, Pauwelstsrasse 30, 52074 Aachen, Germany
| | - Ferdinand Knieling
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Robert Cesnjevar
- Department of Congenital Heart Surgery, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Adrian Regensburger
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Ariawan Purbojo
- Department of Congenital Heart Surgery, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Sven Dittrich
- Department of Pediatric Cardiology, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Frank Münch
- Department of Congenital Heart Surgery, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Joachim Wölfle
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jörg Jüngert
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
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Monitoring cerebrovascular reactivity in pediatric traumatic brain injury: comparison of three methods. Childs Nerv Syst 2021; 37:3057-3065. [PMID: 34212250 DOI: 10.1007/s00381-021-05263-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 06/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To study three different methods of monitoring cerebral autoregulation in children with severe traumatic brain injury. METHODS Prospective cohort study of all children admitted to the pediatric intensive care unit at a university-affiliated hospital with severe TBI over a 4-year period to study three different methods of monitoring cerebral autoregulation: pressure-reactivity index (PRx), transcranial Doppler derived mean flow velocity index (Mx), and near-infrared spectroscopy derived cerebral oximetry index (COx). RESULTS Twelve patients were included in the study, aged 5 months to 17 years old. An empirical regression analyzing dependence of PRx on cerebral perfusion pressure (CPP) displayed the classic U-shaped distribution, with low PRx values (< 0.3) reflecting intact auto-regulation, within the CPP range of 50-100 mmHg. The optimal CPP was 75-80 mmHg for PRx and COx. The correlation coefficients between the three indices were as follows: PRx vs Mx, r = 0.56; p < 0.0001; PRx vs COx, r = 0.16; p < 0.0001; and COx vs Mx, r = 0.15; p = 0.022. The mean PRx with a cutoff value of 0.3 predicted correctly long-term outcome (p = 0.015). CONCLUSIONS PRx seems to be the most robust index to access cerebrovascular reactivity in children with TBI and has promising prognostic value. Optimal CPP calculation is feasible with PRx and COx.
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Huang CH, Wang YC, Chou HW, Huang SC. Near-Infrared Spectroscopy Assessment of Tissue Oxygenation During Selective Cerebral Perfusion for Neonatal Aortic Arch Reconstruction. Front Med (Lausanne) 2021; 8:637257. [PMID: 33996851 PMCID: PMC8119641 DOI: 10.3389/fmed.2021.637257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/11/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Optimal selective cerebral perfusion (SCP) management for neonatal aortic arch surgery has not been extensively studied. We induced mild hypothermia during SCP and used the tissue oxygenation monitor to ensure adequate perfusion during the cardiopulmonary bypass (CPB). Methods: Eight cases were recruited from September 2018 to April 2020. SCP was maintained at 30°C, and CPB was adjusted to achieve a mean right radial artery pressure of 30 mmHg. The near-infrared tissue saturation (NIRS) monitor was applied to assess the right and left brain, flank, and lower extremity during the surgery. Results: During surgery, the mean age was 4.75 days, the mean body weight was 2.92 kg, the CPB duration was 86.5 ±18.7 min, the aortic cross-clamp time was 46.1 ± 12.7 min, and the SCP duration was 14.6±3.4 min. The brain NIRS before, during, and after SCP was 64.2, 67.2, and 71.5 on the left side and 67.9, 66.2, and 70.1 on the right side (p = NS), respectively. However, renal and lower extremity tissue oxygenation, respectively decreased from 61.6 and 62.4 before SCP to 37.7 and 39.9 after SCP (p < 0.05) and then increased to 70.1 and 90.4 after full body flow resumed. No stroke was reported postoperatively. Conclusion: SCP under mild hypothermia can aid in efficient maintenance of brain perfusion during neonatal arch reconstruction. The clinical outcome of this strategy was favorable for up to 20 min, but the safety duration of lower body ischemia warrants further analysis.
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Affiliation(s)
- Chi-Hsiang Huang
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Chia Wang
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hen-Wen Chou
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
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10
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Barkhuizen M, Abella R, Vles JSH, Zimmermann LJI, Gazzolo D, Gavilanes AWD. Antenatal and Perioperative Mechanisms of Global Neurological Injury in Congenital Heart Disease. Pediatr Cardiol 2021; 42:1-18. [PMID: 33373013 PMCID: PMC7864813 DOI: 10.1007/s00246-020-02440-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/17/2020] [Indexed: 12/01/2022]
Abstract
Congenital heart defects (CHD) is one of the most common types of birth defects. Thanks to advances in surgical techniques and intensive care, the majority of children with severe forms of CHD survive into adulthood. However, this increase in survival comes with a cost. CHD survivors have neurological functioning at the bottom of the normal range. A large spectrum of central nervous system dysmaturation leads to the deficits seen in critical CHD. The heart develops early during gestation, and CHD has a profound effect on fetal brain development for the remainder of gestation. Term infants with critical CHD are born with an immature brain, which is highly susceptible to hypoxic-ischemic injuries. Perioperative blood flow disturbances due to the CHD and the use of cardiopulmonary bypass or circulatory arrest during surgery cause additional neurological injuries. Innate patient factors, such as genetic syndromes and preterm birth, and postoperative complications play a larger role in neurological injury than perioperative factors. Strategies to reduce the disability burden in critical CHD survivors are urgently needed.
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Affiliation(s)
- Melinda Barkhuizen
- Department of Pediatrics and Neonatology, Maastricht University Medical Center, Maastricht, The Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Raul Abella
- Department of Pediatric Cardiac Surgery, University of Barcelona, Vall d'Hebron, Spain
| | - J S Hans Vles
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Luc J I Zimmermann
- Department of Pediatrics and Neonatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Diego Gazzolo
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Fetal, Maternal and Neonatal Health, C. Arrigo Children's Hospital, Alessandria, Italy
| | - Antonio W D Gavilanes
- Department of Pediatrics and Neonatology, Maastricht University Medical Center, Maastricht, The Netherlands.
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands.
- Instituto de Investigación e Innovación de Salud Integral, Facultad de Ciencias Médicas, Universidad Católica de Guayaquil, Guayaquil, Ecuador.
- Department of Pediatrics, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
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11
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Finucane E, Jooste E, Machovec KA. Neuromonitoring Modalities in Pediatric Cardiac Anesthesia: A Review of the Literature. J Cardiothorac Vasc Anesth 2020; 34:3420-3428. [DOI: 10.1053/j.jvca.2020.02.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 02/22/2020] [Accepted: 02/28/2020] [Indexed: 12/13/2022]
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12
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Altun D, Doğan A, Arnaz A, Yüksek A, Yalçinbaş YK, Türköz R, Sarioğlu T. Noninvasive monitoring of central venous oxygen saturation by jugular transcutaneous near-infrared spectroscopy in pediatric patients undergoing congenital cardiac surgery. Turk J Med Sci 2020; 50:1280-1287. [PMID: 32490634 PMCID: PMC7491293 DOI: 10.3906/sag-1911-135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/19/2020] [Indexed: 12/26/2022] Open
Abstract
Background and aim In patients undergoing congenital cardiac surgery, it is crucial to maintain oxygen demand-consumption balance. Central venous oxygen saturation (ScvO2) is a useful indicator of oxygen demand and consumption balance which is an invasive method. Near-infrared spectroscopy (NIRS) is a noninvasive, continuous monitoring technique that measures regional tissue oxygenation. NIRS that is placed over the internal jugular vein cutaneous area (NIRSijv) has the potential to show ScvO2 indirectly. In this study, we aimed to determine the correlation between ScvO2 with NIRSijv in pediatric patients undergoing congenital cardiac surgery. Materials and methods Fifty children participated in the study. Four patients were excluded for the inability of internal jugular vein (IJV) catheterization due to technical difficulties. After anesthesia induction, NIRS probes were placed on the IJV site with ultrasound guidance for the measurement of continuous transcutaneous oxygen saturation. The catheter insertion was also done through the IJV from the other side using ultrasound guidance. Cerebral oxygenation monitoring was done using NIRS with a single pediatric probe placed on the right forehead. Values of NIRSijv, cerebral NIRS (NIRSc) and ScvO2, were recorded at certain times until postoperative 24th hour. Results Data were collected at 8 different time points. There was a significant correlation between ScvO2 and NIRSijv in all measurement time points (r = 0.91), (P = 0.001). The mean bias between ScvO2 and NIRSijv was 2.92% and the limits of agreement were from 11% to –5.2%. There was a moderate correlation between ScvO2 and NIRSc (r = 0.45), (P = 0.001). The mean bias between ScvO2 and NIRSc was 2.7% and the limits of agreement were from +26% to –20%. Conclusion In this study, we found a strong correlation between ScvO2 and NIRS measurements taken from the internal jugular vein site. Accordingly, continuous noninvasive monitoring with transcutaneous NIRSijv can be an alternative method as a trend monitor for the central venous oxygen saturation in pediatric cardiac patients undergoing congenital cardiac surgery.
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Affiliation(s)
- Dilek Altun
- Department of Anesthesiology and Reanimation, Vocational School of Health Sciences, Acıbadem Mehmet Ali Aydınlar University, İstanbul, Turkey
| | - Abdullah Doğan
- Department of Cardiovascular Surgery, Acıbadem Bakırköy Hospital, İstanbul, Turkey
| | - Ahmet Arnaz
- Department of Cardiovascular Surgery, Faculty of Medicine, Acıbadem Mehmet Ali Aydınlar University, İstanbul, Turkey
| | - Adnan Yüksek
- Department of Anesthesiology and Reanimation, Acıbadem Bakırköy Hospital, İstanbul, Turkey
| | | | - Riza Türköz
- Department of Cardiovascular Surgery, Acıbadem Bakırköy Hospital, İstanbul, Turkey
| | - Tayyar Sarioğlu
- Department of Pediatric Cardiovascular Surgery, Faculty of Medicine, Acıbadem Mehmet Ali Aydınlar University, İstanbul, Turkey
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13
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Deshpande P, Jain A, Ibarra Ríos D, Bhattacharya S, Dirks J, Baczynski M, McNamara KP, Hahn C, McNamara PJ, Shah P, Guerguerian AM. Combined Multimodal Cerebral Monitoring and Focused Hemodynamic Assessment in the First 72 h in Extremely Low Gestational Age Infants. Neonatology 2020; 117:504-512. [PMID: 32814317 DOI: 10.1159/000508961] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Characteristic changes in cerebral saturation (CrSO2), amplitude-integrated electroencephalography (aEEG), and echocardiography (ECHO) may be associated with intraventricular hemorrhage (IVH); however, the feasibility of their combined application is not known. OBJECTIVE The aim of this work was to investigate the feasibility and safety of combined multimodal cerebral and hemodynamic monitoring in extremely low gestational age (ELGA) infants in the first 72 h after birth. METHODS In this prospective -observational study of 50 infants born between 23 + 0 and 27 + 6 weeks gestation, we measured CrSO2 and aEEG, starting <8 h until 72 h of age. Sequential echocardiography and head ultrasound were performed at 4-8, 12-18, 24-30, and 48-60 h of age. The primary outcome was feasibility of multimodal monitoring, defined as >75% of the subjects satisfying at least 3/4 criteria: (a) CrSO2 and (b) aEEG monitoring each for >75% of the time, and (c) at least 2 out of 4 ECHO and (d) head ultrasounds (at least one by age 24 h). Adverse reactions to sensors, desaturation, and bradycardia during ultrasound studies were recorded. RESULTS Fifty infants were enrolled over 14 months. Multimodal monitoring was feasible in 49 (98%) infants. Forty-one (82%) infants fulfilled all 4 criteria. Mild erythema below CrSO2 sensors lasting 3-8 h without skin breakdown was noted in 8/50 subjects (16%). Desaturation was noted during 17/197 (8.6%) of the ultrasound studies. In total, 26/50 (52%) infants developed IVH (grade I/II, n = 22; grade III/IV, n = 4). CONCLUSION Multimodal monitoring is feasible, safe, and well tolerated in ELGA infants in the first 72 h after birth.
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Affiliation(s)
- Poorva Deshpande
- Mount Sinai Hospital, Toronto, Ontario, Canada, .,Division of Neonatology, University of Toronto, Toronto, Ontario, Canada,
| | - Amish Jain
- Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Neonatology, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Julia Dirks
- Neurosciences and Mental Health Program, Toronto, Ontario, Canada
| | | | | | - Cecil Hahn
- Hospital for Sick Children, Toronto, Ontario, Canada.,Neurosciences and Mental Health Program, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neonatology, University of Toronto, Toronto, Ontario, Canada
| | - Prakesh Shah
- Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Neonatology, University of Toronto, Toronto, Ontario, Canada
| | - Anne-Marie Guerguerian
- Hospital for Sick Children, Toronto, Ontario, Canada.,Neurosciences and Mental Health Program, Toronto, Ontario, Canada
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14
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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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15
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Bojan M. Recent achievements and future developments in neonatal cardiopulmonary bypass. Paediatr Anaesth 2019; 29:414-425. [PMID: 30714261 DOI: 10.1111/pan.13597] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/11/2019] [Accepted: 01/18/2019] [Indexed: 12/21/2022]
Abstract
A primary goal of improving neonatal cardiopulmonary bypass has been making the circuit smaller and reduce the blood contacting surfaces. As bypass circuit size has decreased, bloodless surgery has become possible even in neonates. Since transfusion guidelines are difficult to construct based on existing literature, these technical advances should be taken advantage of in conjunction with an individualized transfusion scheme, based on monitoring of oxygen availability to the tissues. For the majority of neonatal heart operations, several centers have shifted toward normothermic bypass even for complex neonatal surgeries, in order to avoid the adverse effects of hypothermia. Deep hypothermic circulatory arrest is no longer a necessity but an option, and selective antegrade cerebral perfusion has become common practice; however, technical uncertainties with regard to this technique have to be addressed, based on reliable neurologic monitoring. Maintenance of patient-specific heparin concentrations during bypass is another key goal, since neonates have lower baseline antithrombin concentrations and, therefore, a higher risk for inadequate thrombin inhibition and postoperative bleeding. Due to the immaturity of their hemostatic system, the standard coagulation tests alone are inappropriate to guide hemostatic therapy in neonates. The use of indirect heparin concentration assays and global viscoelastic assays in the operating room is likely to represent the optimal strategy, and requires validation in neonates. Monitoring of global and regional indexes of oxygen availability and consumption on bypass have become possible; however, their use in neonates still has outstanding technical issues which should be addressed and hence needs further validation. Due to the immaturity of the neonatal myocardium, single-shot cold cardioplegia solutions are thought to confer the best myocardial protection; their superiority when compared to more conventional modalities, however, remains to be demonstrated.
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Affiliation(s)
- Mirela Bojan
- Congenital Cardiac Unit, Department of Anesthesiology, Marie Lannelongue Hospital, Le Plessis Robinson, France
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16
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AlZubaidi AK, Ethawi Y, Schmölzer GM, Sherif S, Narvey M, Seshia M. Review of Biomedical Applications of Contactless Imaging of Neonates Using Infrared Thermography and Beyond. Methods Protoc 2018; 1:mps1040039. [PMID: 31164579 PMCID: PMC6481091 DOI: 10.3390/mps1040039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/08/2018] [Accepted: 10/08/2018] [Indexed: 11/16/2022] Open
Abstract
The sick preterm infant monitoring is an intriguing job that medical staff in Neonatal Intensive Care Units (NICU) must deal with on a daily basis. As a standards monitoring procedure, preterm infants are monitored via sensors and electrodes that are firmly attached to their fragile and delicate skin and connected to processing monitors. However, an alternative exists in contactless imaging to record such physiological signals (we call it as Physio-Markers), detecting superficial changes and internal structures activities which can be used independently of, or aligned with, conventional monitors. Countless advantages can be gained from unobtrusive monitoring not limited to: (1) quick data generation; (2) decreasing physical and direct contact with skin, which reduces skin breakdown and minimizes risk of infection; and (3) reduction of electrodes and probes connected to clinical monitors and attached to the skin, which allows greater body surface-area for better care. This review is an attempt to build a solid ground for and to provide a clear perspective of the potential clinical applications of technologies inside NICUs that use contactless imaging modalities such as Visible Light Imaging (VLI), Near Infrared Spectroscopy (NIRS), and Infrared Thermography (IRT).
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Affiliation(s)
- Abbas K AlZubaidi
- Biomedical Engineering Division, University of Saskatchewan, Campus Dr 9, Saskatoon, SK S7N 5A5, Canada.
| | - Yahya Ethawi
- Section of Neonatology, Winnipeg Regional Health Authority, Winnipeg, MB R3B 1E2, Canada.
| | - Georg M Schmölzer
- Section of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, AB T6G 1C9, Canada.
| | - Sherif Sherif
- Department of Electrical and Computer Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada.
| | - Michael Narvey
- Section of Neonatology, Winnipeg Regional Health Authority, Winnipeg, MB R3B 1E2, Canada.
| | - Molly Seshia
- Section of Neonatology, Department of Pediatrics, University of Manitoba, Winnipeg, MB R3A 1S1, Canada.
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17
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Ferradal SL, Yuki K, Vyas R, Ha CG, Yi F, Stopp C, Wypij D, Cheng HH, Newburger JW, Kaza AK, Franceschini MA, Kussman BD, Grant PE. Non-invasive Assessment of Cerebral Blood Flow and Oxygen Metabolism in Neonates during Hypothermic Cardiopulmonary Bypass: Feasibility and Clinical Implications. Sci Rep 2017; 7:44117. [PMID: 28276534 PMCID: PMC5343476 DOI: 10.1038/srep44117] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 02/02/2017] [Indexed: 02/01/2023] Open
Abstract
The neonatal brain is extremely vulnerable to injury during periods of hypoxia and/or ischemia. Risk of brain injury is increased during neonatal cardiac surgery, where pre-existing hemodynamic instability and metabolic abnormalities are combined with long periods of low cerebral blood flow and/or circulatory arrest. Our understanding of events associated with cerebral hypoxia-ischemia during cardiopulmonary bypass (CPB) remains limited, largely due to inadequate tools to quantify cerebral oxygen delivery and consumption non-invasively and in real-time. This pilot study aims to evaluate cerebral blood flow (CBF) and oxygen metabolism (CMRO2) intraoperatively in neonates by combining two novel non-invasive optical techniques: frequency-domain near-infrared spectroscopy (FD-NIRS) and diffuse correlation spectroscopy (DCS). CBF and CMRO2 were quantified before, during and after deep hypothermic cardiopulmonary bypass (CPB) in nine neonates. Our results show significantly decreased CBF and CMRO2 during hypothermic CPB. More interestingly, a change of coupling between both variables is observed during deep hypothermic CPB in all subjects. Our results are consistent with previous studies using invasive techniques, supporting the concept of FD-NIRS/DCS as a promising technology to monitor cerebral physiology in neonates providing the potential for individual optimization of surgical management.
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Affiliation(s)
- Silvina L Ferradal
- Fetal-Neonatal Neuroimaging &Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Koichi Yuki
- Department of Anesthesiology, Perioperative &Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rutvi Vyas
- Fetal-Neonatal Neuroimaging &Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher G Ha
- Fetal-Neonatal Neuroimaging &Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Francesca Yi
- Fetal-Neonatal Neuroimaging &Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian Stopp
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Henry H Cheng
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aditya K Kaza
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria A Franceschini
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Barry D Kussman
- Department of Anesthesiology, Perioperative &Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - P Ellen Grant
- Fetal-Neonatal Neuroimaging &Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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18
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Friesen RH. Landmark papers in pediatric cardiac anesthesia: documenting the history of the specialty. Paediatr Anaesth 2016; 26:1047-1052. [PMID: 27734558 DOI: 10.1111/pan.13011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2016] [Indexed: 11/30/2022]
Abstract
Pediatric cardiac anesthesia has developed over the past eight decades into a specialty delivering complex clinical care and contributing remarkable scientific progress. The history of this development can be traced through journal articles that mark the strides of the specialty. This article discusses journal articles, chosen by the author, that he considers had a significant impact on the practice of pediatric cardiac anesthesia or are of historical interest.
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Affiliation(s)
- Robert H Friesen
- Department of Anesthesiology, Children's Hospital Colorado and University of Colorado School of Medicine, Denver, CO, USA.
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19
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Williams GD, Ramamoorthy C. Brain Monitoring and Protection During Pediatric Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2016; 11:23-33. [PMID: 17484171 DOI: 10.1177/1089253206297412] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
With advances in medical care, survival after cardiac surgery for congenital heart disease has dramatically improved, and attention is increasingly focused on longterm functional morbidities, especially neurodevelopmental outcomes, with their profound consequences to patients and society. There are multiple reasons for concern about brain injury. Some cardiac defects are associated with brain anomalies and altered cerebral blood flow regulation. Brain imaging studies have demonstrated that injury to gray and white matter is quite frequent before heart surgery in neonates. Cardiopulmonary bypass and deep hypothermic circulatory arrest are associated with shortand longer-term adverse neurologic outcome. Additional brain injury can occur during the patient's recovery from surgery. Strategies to optimize neurologic outcome continue to evolve. With new technological developments, perioperative neurologic monitoring of small children has become easier, and data suggest these modalities usefully identify adverse neurologic events and might predict outcome. Monitoring methods to be discussed include processed electroencephalography, near infrared spectroscopy, and transcranial Doppler ultrasound. Alternative perfusion techniques to deep hypothermic circulatory arrest have been developed, such as regional antegrade cerebral perfusion during cardiopulmonary bypass. Other neuroprotective strategies employed during open-heart surgery include temperature regulation, acid-base management, degree of hemodilution, blood glucose control and anti-inflammatory therapies. Evidence of the impact of these measures on neurologic outcome is examined, and deficiencies in our current understanding of neurologic function in children with congenital heart disease are identified.
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Affiliation(s)
- Glyn D Williams
- Department of Anesthesia, Stanford University Medical School, California 94305, USA.
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20
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Doblar DD. Intraoperative Transcranial Ultrasonic Monitoring for Cardiac and Vascular Surgery. Semin Cardiothorac Vasc Anesth 2016; 8:127-45. [PMID: 15247999 DOI: 10.1177/108925320400800206] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The brain is the only organ not routinely monitored by any direct method during the administration of anesthesia. Anesthesiologists rely primarily on indirect physiologic evidence provided by blood pressure, peripheral pulse oximetry, heart rate, and respiratory and anesthetic gas concentrations to determine that brain blood flow and oxygenation are adequate. The reasons for this practice are that: (1) after millions of anesthetics significant numbers of adverse neurologic outcomes have not occurred, (2) the interpretation of transcranial Doppler, electroencephalogram, and near-infrared cerebral oximetry requires experienced personnel, and (3) the evidence of cost-benefit to support monitoring is limited. Brain monitoring generally has been confined to procedures where the brain is exposed to unique insults and risks specific to the procedures and where reliance on indirect physiologic evidence of cerebral integrity has been proven to be unreliable. Transcranial Doppler monitoring is valuable in the assessment of established surgical techniques, refinement of recent surgical techniques, and development of new techniques and instrumentation. Brain monitoring with transcranial Doppler is of particular value when deviations from established surgical or anesthetic techniques may place the brain at risk for cerebral hyper-or hypoperfusion, gaseous or particulate embolization, or their combined effects. This paper discusses applications of transcranial Doppler in coronary artery bypass surgery, aortic arch procedures, pediatric cardiac surgery, carotid endarterectomy, and a few other special cases. The insight into cerebral physiology is unique to the continuous window on the brain that transcranial Doppler provides.
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Affiliation(s)
- Dennis D Doblar
- Department of Anesthesiology, The University of Alabama, Birmingham, Alabama 35249-6810, USA.
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21
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Cesnjevar RA, Purbojo A, Muench F, Juengert J, Rueffer A. Goal-directed-perfusion in neonatal aortic arch surgery. Transl Pediatr 2016; 5:134-141. [PMID: 27709094 PMCID: PMC5035760 DOI: 10.21037/tp.2016.07.03] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Reduction of mortality and morbidity in congenital cardiac surgery has always been and remains a major target for the complete team involved. As operative techniques are more and more standardized and refined, surgical risk and associated complication rates have constantly been reduced to an acceptable level but are both still present. Aortic arch surgery in neonates seems to be of particular interest, because perfusion techniques differ widely among institutions and an ideal form of a so called "total body perfusion (TBP)" is somewhat difficult to achieve. Thus concepts of deep hypothermic circulatory arrest (DHCA), regional cerebral perfusion (RCP/with cardioplegic cardiac arrest or on the perfused beating heart) and TBP exist in parallel and all carry an individual risk for organ damage related to perfusion management, chosen core temperature and time on bypass. Patient safety relies more and more on adequate end organ perfusion on cardiopulmonary bypass, especially sensitive organs like the brain, heart, kidney, liver and the gut, whereby on adequate tissue protection, temperature management and oxygen delivery should be visualized and monitored.
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Affiliation(s)
- Robert Anton Cesnjevar
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg, Erlangen, Germany
| | - Ariawan Purbojo
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg, Erlangen, Germany
| | - Frank Muench
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg, Erlangen, Germany
| | - Joerg Juengert
- Department of Pediatrics, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg, Erlangen, Germany
| | - André Rueffer
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg, Erlangen, Germany
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22
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Lee JH, Min SH, Song IK, Kim HS, Kim CS, Kim JT. Control of Cardiopulmonary Bypass Flow Rate Using Transfontanellar Ultrasonography and Cerebral Oximetry During Selective Antegrade Cerebral Perfusion. J Cardiothorac Vasc Anesth 2016; 30:186-91. [DOI: 10.1053/j.jvca.2015.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Indexed: 11/11/2022]
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Intraoperative trans-fontanellar cerebral ultrasonography in infants during cardiac surgery under cardiopulmonary bypass: an observational study. J Clin Monit Comput 2015; 31:159-165. [DOI: 10.1007/s10877-015-9815-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/14/2015] [Indexed: 11/26/2022]
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Morton PD, Ishibashi N, Jonas RA, Gallo V. Congenital cardiac anomalies and white matter injury. Trends Neurosci 2015; 38:353-63. [PMID: 25939892 PMCID: PMC4461528 DOI: 10.1016/j.tins.2015.04.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/01/2015] [Accepted: 04/02/2015] [Indexed: 12/17/2022]
Abstract
Cardiac abnormalities are the most common birth defects. Derangement of circulatory flow affects many vital organs; without proper supply of oxygenated blood, the brain is particularly vulnerable. Although surgical interventions have greatly reduced mortality rates, patients often suffer an array of neurological deficits throughout life. Neuroimaging provides a macroscopic assessment of brain injury and has shown that white matter (WM) is at risk. Oligodendrocytes and myelinated axons have been identified as major targets of WM injury, but still little is known about how congenital heart anomalies affect the brain at the cellular level. Further integration of animal model studies and clinical research will define novel therapeutic targets and new standards of care to prevent developmental delay associated with cardiac abnormalities.
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Affiliation(s)
- Paul D Morton
- Center for Neuroscience Research and Children's National Heart Institute, Children's National Medical Center, Washington, DC 20010, USA
| | - Nobuyuki Ishibashi
- Center for Neuroscience Research and Children's National Heart Institute, Children's National Medical Center, Washington, DC 20010, USA
| | - Richard A Jonas
- Center for Neuroscience Research and Children's National Heart Institute, Children's National Medical Center, Washington, DC 20010, USA
| | - Vittorio Gallo
- Center for Neuroscience Research and Children's National Heart Institute, Children's National Medical Center, Washington, DC 20010, USA.
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25
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Guzmán-Pruneda FA, Fraser CD. Neuroprotective strategies--what do we really need to know? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2014; 17:77-80. [PMID: 24725721 DOI: 10.1053/j.pcsu.2014.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
While preliminary data are encouraging, definitive data are lacking to conclusively demonstrate the benefit of perioperative neurologic monitoring in improving neurodevelopmental outcomes in children who require surgery for congenital heart disease. Nonetheless, in the current era, some form of perioperative neurologic monitoring is important. Strategies include bicortical near infrared spectroscopy monitoring in the pre- and postoperative periods along with bicortical near infrared spectroscopy and transcranial Doppler intraoperatively. These monitors provide real-time information concerning cerebral oxygen delivery and blood flow. These strategies will allow us to refine treatments to optimize neurodevelopmental potential in children with congenital heart disease.
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Affiliation(s)
- Francisco A Guzmán-Pruneda
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Charles D Fraser
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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26
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Kim JW, Shin WJ, Park I, Chung IS, Gwak M, Hwang GS. Splanchnic oxygen saturation immediately after weaning from cardiopulmonary bypass can predict early postoperative outcomes in children undergoing congenital heart surgery. Pediatr Cardiol 2014; 35:587-95. [PMID: 24165823 DOI: 10.1007/s00246-013-0824-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 10/03/2013] [Indexed: 10/26/2022]
Abstract
This study compared the abilities of cerebral, renal, and splanchnic regional oxygen saturation (rSO2) immediately after weaning from cardiopulmonary bypass (CPB) to predict early postoperative outcomes for children undergoing congenital heart surgery. The study enrolled 73 children (ages 0.1-72 months) undergoing corrective or palliative cardiac surgery requiring CPB. Laboratory and hemodynamic variables were analyzed at the time of successful weaning from CPB. Using near-infrared spectroscopy, cerebral, renal, and splanchnic rSO2 values were obtained simultaneously. Early postoperative outcome measures included the maximum vasoactive inotropic score (VIS(max)) during the first 36 postoperative hours, the duration of mechanical ventilation, and the postoperative hospital length of stay. In the univariate analysis, cerebral, renal, and splanchnic rSO2 values correlated significantly with early postoperative outcomes. However, splanchnic rSO2 was the only independent factor predicting VIS(max) (β = -0.302, P = 0.021), duration of mechanical ventilation (β = -0.390, P = 0.002), and postoperative hospital length of stay (β = -0.340, P = 0.001) by multivariate analyses. Splanchnic rSO2 had a larger receiver operating characteristic area under the curve (AUC) for determining high VIS(max), prolonged mechanical ventilation, and longer postoperative hospital stay (AUC 0.775, 0.792, and 0.776, respectively) than cerebral (AUC 0.630, 0.638, and 0.632, respectively) and renal (AUC 0.703, 0.716, and 0.715, respectively) rSO2. After weaning from CPB, splanchnic rSO2 may be superior to rSO2 measured from brain and kidney in predicting an increased requirement for vasoactive inotropic support, a prolonged mechanical ventilation, and a longer postoperative hospital stay for children.
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Affiliation(s)
- Jung-Won Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Guo Z, Hu RJ, Zhu DM, Zhu ZQ, Zhang HB, Wang W. Usefulness of Deep Hypothermic Circulatory Arrest and Regional Cerebral Perfusion in Children. Ther Hypothermia Temp Manag 2013; 3:126-131. [PMID: 24066266 DOI: 10.1089/ther.2013.0006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
To compare the safety and usefulness of deep hypothermic circulatory arrest (DHCA) and regional cerebral perfusion (RCP) during pediatric open heart surgery. Between January 1, 2004 and September 30, 2012, 1250 children with congenital cardiac defect underwent corrective operation with the DHCA or RCP technique in the Shanghai Children's Medical Center. Of them, 947 cases underwent the operation with the aid of DHCA (DHCA group), and 303 cases with RCP (RCP group). The mean DHCA time was 30.64±15.81 (7-63) minutes and mean RCP time was 36.18±12.86 (10-82) minutes. The mortality rate was 7.18% (68/947) and 6.60% (20/30) in two groups, respectively. The postoperative incidences of temporary and permanent neurological dysfunction were 6.23% (59/947) in the DHCA group and 2.64% (8/303) in the RCP group (p<0.01). The incidence of other complications such as low cardiac output, renal dysfunction, and lung issues are similar in both groups. RCP is a reliable technique for cerebral protection and it facilitates time-consuming corrected procedures for complex congenital cardiac defect repair procedures.
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Affiliation(s)
- Zheng Guo
- Department of Pediatric Thoracic and cardiovascular Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine , Shanghai, People's Republic of China
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28
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[Usefulness of Bispectral Index (BIS) monitoring for early detection of cerebral hypoperfusions]. ACTA ACUST UNITED AC 2013; 32:653-8. [PMID: 23953319 DOI: 10.1016/j.annfar.2013.07.802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 07/03/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The goal of the study was to assess whether clinically significant cerebral hypoperfusion in awake patients would be associated with some alterations in the values of the bispectral index (BIS) monitoring. STUDY DESIGN Observational study. POPULATION AND METHODS We monitored the BIS during endovascular carotid artery occlusion testing in awake patients. RESULTS Twenty-eight patients were included. Twenty-one adequately tolerated the procedure. Their BIS value remained stable throughout the procedure. Four patients had poor angiographic tolerance, but no clinical symptoms. Their BIS value slightly decreased during the test (minimal BIS: 83 [79-87]). Three patients had poor clinical and angiographic tolerance of the occlusion. They all experienced an immediate and dramatic decrease in their BIS value (minimal BIS: ipsilateral to clamping: 50 [45-60]; contralateral to clamping: 48 [45-52]). In all patients, the clinical symptoms and the BIS normalized after deflating the occlusion balloon. CONCLUSION In awake patients, the observed values of the BIS monitoring seem to be associated with clinically relevant cerebral hypoperfusion.
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29
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Turkoz R, Saritas B, Ozker E, Vuran C, Yoruker U, Balci S, Altun D, Turkoz A. Selective cerebral perfusion with aortic cannulation and short-term hypothermic circulatory arrest in aortic arch reconstruction. Perfusion 2013; 29:70-4. [PMID: 23863488 DOI: 10.1177/0267659113496581] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The deep hypothermic circulatory arrest (DHCA) technique has been used in aortic arch and isthmus hypoplasia for many years. However, with the demonstration of the deleterious effects of prolonged DHCA, selective cerebral perfusion (SCP) has started to be used in aortic arch repair. For SCP, perfusion via the innominate artery route is generally preferred (either direct innominate artery cannulation or re-routing of the cannula in the aorta is used). Herein, we describe our technique and the result of arch reconstruction in combination with selective cerebral and myocardial perfusion (SCMP) and short-term total circulatory arrest (TCA) (5-10 min) through ascending aortic cannulation. METHODS Thirty-seven cases with aortic arch and isthmus hypoplasia accompanying cardiac defects were operated on with SCMP and short TCA in Baskent University Istanbul Research and Training Hospital between January 2007 and Sep 2012. There were 17 cases with ventricular septal defect (VSD)-coarctation with aortic arch hypoplasia (CoAAH), 4 cases of transposition of the great arteries-VSD-CoAAH, 4 cases of Taussing Bing Anomaly-CoAAH, 2 cases complete atrioventricular canal defect-CoAAH, 3 cases single ventricle-CoAAH, 3 cases of type A interruption-VSD, 2 subvalvular aortic stenosis-CoAAH and 2 cases of isolated CoAAH. The aorta was cannulated in the middle of the ascending aorta in all cases. The cross-clamp was applied to the aortic arch distal to either the innominate artery or the left carotid artery. In addition, a side-biting clamp was applied to the descending aorta. The aorta between these two clamps was reconstructed with gluteraldehyde-treated autogeneous pericardium, using SCMP. The proximal arch and distal ascending aorta reconstructions were carried out under short TCA. RESULTS The mean age of the patients was 2.5 ± 2 months. The mean cardiopulmonary bypass and cross-clamp times were 144 ± 58 and 43 ± 27 minutes, respectively. The mean SCMP and descending aorta ischemia times were 22.6 ± 4.8 and 27 ± 6.3 minutes, respectively. Mean TCA time was 7.6 ± 2.1 minutes (min: 4, max 10 min). The mean in-hospital stay time was 8.6 ± 1.9 days. None of the cases operated with this technique had neurological defects. The mortality rate was 2.7% (1 patient). CONCLUSION SCMP with aortic cannulation and short TCA (under 10 minutes) in aortic reconstruction is safe and practical in this high-risk patient group.
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Affiliation(s)
- R Turkoz
- Baskent University, Istanbul Teaching and Medical Research Center, Istanbul, Turkey
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30
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Khan MS, Fraser CD. Neonatal brain protection in cardiac surgery and the role of intraoperative neuromonitoring. World J Pediatr Congenit Heart Surg 2013; 3:114-9. [PMID: 23804694 DOI: 10.1177/2150135111425934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Improving mortality rates in children undergoing surgery for congenital heart disease has enabled a shift in focus to improving morbidity, particularly with respect to neurological complications. Various factors have been implicated in influencing neurological outcomes. We share our experience in formulating a customized cardiopulmonary bypass (CPB) protocol based on currently available evidence. Theoretical advantages of intraoperative neuromonitoring during CPB, specifically use of near-infrared spectroscopy, will be discussed in the context of methodologies to monitor cerebral perfusion during surgery.
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Affiliation(s)
- Muhammad S Khan
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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31
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Direct Innominate Artery Cannulation for Antegrade Cerebral Perfusion in Neonates Undergoing Arch Reconstruction. Ann Thorac Surg 2013; 95:956-61. [DOI: 10.1016/j.athoracsur.2012.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 10/09/2012] [Accepted: 10/11/2012] [Indexed: 01/07/2023]
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32
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MORENO GE, PILÁN ML, MANARA C, MAGLIOLA R, VASSALLO JC, BALESTRINI M, LENZ AM, KRYNSKI M, ALTHABE M, LANDRY L. Regional venous oxygen saturation versus mixed venous saturation after paediatric cardiac surgery. Acta Anaesthesiol Scand 2013; 57:373-9. [PMID: 23210461 DOI: 10.1111/aas.12016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Central venous oxygen saturation (ScvO2) remains the gold standard surrogate for tissue oxygen extraction in paediatric cardiac surgery. Near-infrared spectroscopy (NIRS) has been developed as a non-invasive diagnostic tool for regional oxygen saturation. The aim was to compare regional oxygen saturation measured by NIRS with ScvO2 in postoperative paediatric cardiac patients. METHODS In this prospective study, we included newborns and infants younger than 45 days undergoing heart surgery. We recorded continuous ScvO2 and NIRS regional saturation placed on the forehead (B) and right flank (S) for 48 h postoperatively. A Bland-Altman's analysis was used to assess the agreement between these measurements. RESULTS A total of 23 patients were included with a median age of 12 days (2-46) and median weight of 3.1 kg (2.3-4.47). The mean difference (MD) ScvO2- B NIRS was 10.45% with limits of agreement (LOA) -17.23 to 38.13% and ScvO2- S NIRS MD 7.16% with LOA: -25.51 to 39.84%. The single ventricle ScvO2- S NIRS subgroup had MD within ± 5%; however, wide LOA was observed. The remaining subgroups showed MD nearly above ± 5%, with wide LOA. CONCLUSIONS The regional oxygen saturation of brain and kidney did not match ScvO2 as estimation of global tissue perfusion. Nevertheless, NIRS may still provide information regarding regional circulation that may help in the management of neonatal cardiac surgery patients.
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Affiliation(s)
- G. E. MORENO
- Cardiac Intensive Care Unit (UCI35); Hospital de Pediatría ‘Dr Juan P. Garrahan’; Ciudad Autónoma de Buenos Aires; Argentina
| | - M. L. PILÁN
- Cardiac Intensive Care Unit (UCI35); Hospital de Pediatría ‘Dr Juan P. Garrahan’; Ciudad Autónoma de Buenos Aires; Argentina
| | - C. MANARA
- Cardiac Intensive Care Unit (UCI35); Hospital de Pediatría ‘Dr Juan P. Garrahan’; Ciudad Autónoma de Buenos Aires; Argentina
| | - R. MAGLIOLA
- Cardiac Intensive Care Unit (UCI35); Hospital de Pediatría ‘Dr Juan P. Garrahan’; Ciudad Autónoma de Buenos Aires; Argentina
| | - J. C. VASSALLO
- Education Coordinator; Hospital de Pediatría ‘Dr Juan P. Garrahan’; Ciudad Autónoma de Buenos Aires; Argentina
| | - M. BALESTRINI
- Cardiac Intensive Care Unit (UCI35); Hospital de Pediatría ‘Dr Juan P. Garrahan’; Ciudad Autónoma de Buenos Aires; Argentina
| | - A. M. LENZ
- Cardiac Intensive Care Unit (UCI35); Hospital de Pediatría ‘Dr Juan P. Garrahan’; Ciudad Autónoma de Buenos Aires; Argentina
| | - M. KRYNSKI
- Cardiac Intensive Care Unit (UCI35); Hospital de Pediatría ‘Dr Juan P. Garrahan’; Ciudad Autónoma de Buenos Aires; Argentina
| | - M. ALTHABE
- Cardiac Intensive Care Unit (UCI35); Hospital de Pediatría ‘Dr Juan P. Garrahan’; Ciudad Autónoma de Buenos Aires; Argentina
| | - L. LANDRY
- Cardiac Intensive Care Unit (UCI35); Hospital de Pediatría ‘Dr Juan P. Garrahan’; Ciudad Autónoma de Buenos Aires; Argentina
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Low-flow antegrade cerebral perfusion attenuates early renal and intestinal injury during neonatal aortic arch reconstruction. J Thorac Cardiovasc Surg 2012; 144:1323-8, 1328.e1-2. [DOI: 10.1016/j.jtcvs.2012.03.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 02/15/2012] [Accepted: 03/12/2012] [Indexed: 01/05/2023]
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Andropoulos DB, Easley RB, Brady K, McKenzie ED, Heinle JS, Dickerson HA, Shekerdemian LS, Meador M, Eisenman C, Hunter JV, Turcich M, Voigt RG, Fraser CD. Neurodevelopmental outcomes after regional cerebral perfusion with neuromonitoring for neonatal aortic arch reconstruction. Ann Thorac Surg 2012; 95:648-54; discussion 654-5. [PMID: 22766302 DOI: 10.1016/j.athoracsur.2012.04.070] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 04/16/2012] [Accepted: 04/18/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND In this study we report magnetic resonance imaging (MRI) brain injury and 12-month neurodevelopmental outcomes when regional cerebral perfusion (RCP) is used for neonatal aortic arch reconstruction. METHODS Fifty-seven neonates receiving RCP during aortic arch reconstruction were enrolled in a prospective outcome study. RCP flows were determined by near-infrared spectroscopy and transcranial Doppler monitoring. Brain MRI was performed preoperatively and 7 days postoperatively. Bayley Scales of Infant Development III was performed at 12 months. RESULTS Mean RCP time was 71 ± 28 minutes (range, 5 to 121 minutes) and mean flow was 56.6 ± 10.6 mL/kg/min. New postoperative MRI brain injury was seen in 40% of patients. For 35 RCP patients at age 12 months, mean Bayley Scales III Composite standard scores were: Cognitive, 100.1 ± 14.6 (range, 75 to 125); Language, 87.2 ± 15.0 (range, 62 to 132); and Motor, 87.9 ± 16.8 (range, 58 to 121). Increasing duration of RCP was not associated with adverse neurodevelopmental outcomes. CONCLUSIONS Neonatal aortic arch repair with RCP using a neuromonitoring strategy results in 12-month cognitive outcomes that are at reference population norms. Language and motor outcomes are lower than the reference population norms by 0.8 to 0.9 standard deviations. The neurodevelopmental outcomes in this RCP cohort demonstrate that this technique is effective and safe in supporting the brain during neonatal aortic arch reconstruction.
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Affiliation(s)
- Dean B Andropoulos
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77030, USA.
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35
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Andropoulos DB, Easley RB, Brady K, McKenzie ED, Heinle JS, Dickerson HA, Shekerdemian L, Meador M, Eisenman C, Hunter JV, Turcich M, Voigt RG, Fraser CD. Changing expectations for neurological outcomes after the neonatal arterial switch operation. Ann Thorac Surg 2012; 94:1250-5; discussion 1255-6. [PMID: 22748448 DOI: 10.1016/j.athoracsur.2012.04.050] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 04/08/2012] [Accepted: 04/12/2012] [Indexed: 01/02/2023]
Abstract
BACKGROUND Expectations for outcomes after the neonatal arterial switch operation (ASO) continue to change. This cohort study describes neurodevelopmental outcomes at age 12 months after neonatal ASO, and analyzes both modifiable and nonmodifiable factors for association with adverse outcomes. METHODS Patients who underwent an ASO (n=30) were enrolled in a prospective outcome study, with comprehensive clinical data collection during the first 12 months of life. Brain magnetic resonance imaging was done preoperatively and 7 days postoperatively, and the Bayley Scales of Infant Development III was performed at age 12 months. RESULTS Ten of 30 patients (33%) had preoperative magnetic resonance imaging injury; 13 of 30 patients (43%) had new postoperative magnetic resonance imaging injury. Twenty patients (67%) had Bayley Scales of Infant Development III: Cognitive Composite standard score mean was 104.8±15.0, Language Composite standard score median was 90.0 (25th to 75th percentile, 83 to 94), and Motor Composite standard score mean was 92.3±14.2. Best subsets multivariable analysis found associations between lower preoperative and intraoperative cerebral oxygen saturation, preoperative magnetic resonance imaging brain injury, total bypass time, and total midazolam dose and lower Bayley Scales of Infant Development III scores at age 12 months. CONCLUSIONS At 12 months after ASO, neurodevelopmental outcome means were within normal population ranges. The new associations reported in this study between potentially modifiable perioperative factors and outcomes require investigations in larger patient cohorts. Beyond survival, which was 100% in this cohort, factors influencing quality of life including neurodevelopmental outcomes should be routinely investigated in studies of ASO patients.
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Affiliation(s)
- Dean B Andropoulos
- Department of Pediatrics, Baylor College of Medicine, Division of Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital, Houston, Texas 77030, USA.
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Carotti A. Postoperative neurodevelopmental outcome of patients with hypoplastic left heart complex: hybrid versus Norwood strategy. Eur J Cardiothorac Surg 2012; 42:40-1. [PMID: 22368188 DOI: 10.1093/ejcts/ezs010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Algra SO, Kornmann VNN, van der Tweel I, Schouten ANJ, Jansen NJG, Haas F. Increasing duration of circulatory arrest, but not antegrade cerebral perfusion, prolongs postoperative recovery after neonatal cardiac surgery. J Thorac Cardiovasc Surg 2012; 143:375-82. [PMID: 21906758 DOI: 10.1016/j.jtcvs.2011.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Revised: 07/18/2011] [Accepted: 08/04/2011] [Indexed: 11/15/2022]
Affiliation(s)
- Selma O Algra
- Department of Pediatric Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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38
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Toyama S, Sakai H, Ito S, Suzuki Y, Kondo Y. Cerebral hypoperfusion during pediatric cardiac surgery detected by combined bispectral index monitoring and transcranial doppler ultrasonography. J Clin Anesth 2011; 23:498-501. [PMID: 21911197 DOI: 10.1016/j.jclinane.2010.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Revised: 09/17/2010] [Accepted: 09/22/2010] [Indexed: 10/17/2022]
Abstract
Bispectral index monitoring (BIS) measures depth of anesthesia and sedation. The case of a neonatal patient who underwent surgical repair for a double aortic arch is presented. During surgery, BIS decreased to 0, and cerebral blood flow (CBF), as measured by transcranial doppler ultrasonography, could not be detected immediately after clamping of the arch. BIS returned to baseline, and CBF was detected only after the aortic arch was unclamped. The arch was then carefully reclamped during close BIS and CBF monitoring.
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Affiliation(s)
- Satoshi Toyama
- Department of Anesthesiology, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara-City, Chiba, 299-0111, Japan.
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Su XW, Guan Y, Barnes M, Clark JB, Myers JL, Undar A. Improved cerebral oxygen saturation and blood flow pulsatility with pulsatile perfusion during pediatric cardiopulmonary bypass. Pediatr Res 2011; 70:181-5. [PMID: 21544006 DOI: 10.1203/pdr.0b013e3182226b75] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Brain monitoring techniques near-infrared spectroscopy (NIRS) and transcranial Doppler (TCD) ultrasound were used in pediatric patients undergoing cardiopulmonary bypass for congenital heart defect (CHD) repair to analyze the effect of pulsatile or nonpulsatile flow on brain protection. Regional cerebral oxygen saturation (rSO2) and cerebrovascular pulsatility index (PI) were measured by NIRS and TCD, respectively, in 111 pediatric patients undergoing bypass for CHD repair randomized to pulsatile (n = 77) or nonpulsatile (n = 34) perfusion. No significant differences in demographic and intraoperative data, including surgical risk stratification, existed between groups. Patients undergoing pulsatile perfusion had numerically lower decreases in rSO2 from baseline for all time points analyzed compared with the nonpulsatile group, with significant ∼12% lower decreases at 40 and 60 min after crossclamp. Patients undergoing pulsatile perfusion had numerically lower decreases in PI from baseline for the majority of time points compared with the nonpulsatile group, with significant ∼30% lower decreases between 5 and 40 min after crossclamp. Pulsatile flow has advantages over nonpulsatile flow as measured by NIRS and TCD, especially at advanced time points, which may improve postoperative neurodevelopmental outcomes.
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Affiliation(s)
- Xiaowei W Su
- Department of Pediatrics, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania 17033, USA
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40
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Lee JK, Blaine Easley R, Brady KM. Neurocognitive monitoring and care during pediatric cardiopulmonary bypass-current and future directions. Curr Cardiol Rev 2011; 4:123-39. [PMID: 19936287 PMCID: PMC2779352 DOI: 10.2174/157340308784245766] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Revised: 12/17/2007] [Accepted: 12/21/2007] [Indexed: 11/22/2022] Open
Abstract
Neurologic injury in patients with congenital heart disease remains an important source of morbidity and mortality. Advances in surgical repair and perioperative management have resulted in longer life expectancies for these patients. Current practice and research must focus on identifying treatable risk factors for neurocognitive dysfunction, advancing methods for perioperative neuromonitoring, and refining treatment and care of the congenital heart patient with potential neurologic injury. Techniques for neuromonitoring and future directions will be discussed.
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Affiliation(s)
- Jennifer K Lee
- Departments of Anesthesiology/Critical Care Medicine and Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Durandy Y, Rubatti M, Couturier R. Near Infrared Spectroscopy during pediatric cardiac surgery: errors and pitfalls. Perfusion 2011; 26:441-6. [DOI: 10.1177/0267659111408755] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As a result of improvements in early outcomes, long-term neurologicalal outcomes are becoming a major issue in pediatric cardiac surgery. The mechanisms of brain injury are numerous, but a vast majority of injuries are impervious to therapy and only a few are modifiable. The quality of perfusion during cardiac surgery is a modifiable factor and cerebral monitoring during bypass is the way to assess the quality of intra-operative cerebral perfusion. Near infrared spectroscopy (NIRS), as a diagnostic tool, has gained in popularity within the perfusion community. However, NIRS is becoming the standard of care before its scientific validation. This manuscript relates four clinical cases, demonstrating the limitations of NIRS monitoring during pediatric cardiac surgery as well as uncertainties about the interpretation of the recorded values. The clinical relevance of cerebral oxymetry is needed before the use of NIRS as a decision making tool. Multimodal brain monitoring with NIRS, trans-cranial Doppler and electroencephalogram are currently under way in several pediatric centers. The benefit of this time-consuming and expensive monitoring system has yet to be demonstrated.
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Affiliation(s)
- Y Durandy
- Department of Perfusion and Intensive Care, Institut Hospitalier Jacques Cartier, Massy, France
| | - M Rubatti
- Department of Anesthesiology, Institut Hospitalier Jacques Cartier, Massy, France
| | - R Couturier
- Department of Anesthesiology, Institut Hospitalier Jacques Cartier, Massy, France
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Abstract
Reflectance near-infrared spectroscopy has been used to measure cortical tissue oximetry for more than 30 years. In that time, many centers have adopted the routine use of the cerebral oximeter for children having repair of congenital heart lesions, while some prominent academic centers have resisted routine use of these monitors citing lack of definitive evidence for outcome benefit. In this review, we provide an overview of the method used to measure cerebral oximetry, as well as validation and clinical outcome data that have accrued from the use of cerebral oximeters. We discuss the peculiarities of evidentiary review for monitoring devices, and the confounding errors that occur when a monitor is evaluated as a therapeutic intervention. We outline the physiologic basis of cerebral desaturation and the shifts in practice that have occurred with implementation of NIRS monitoring.
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Affiliation(s)
- Nicholette Kasman
- Department of Pediatric Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
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Miyaji K, Miyamoto T, Kohira S, Yoshii T, Itatani KI, Sato H, Inoue N. The effectiveness of high-flow regional cerebral perfusion in Norwood stage I palliation. Eur J Cardiothorac Surg 2011; 40:1215-20. [PMID: 21470870 DOI: 10.1016/j.ejcts.2011.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 02/03/2011] [Accepted: 02/04/2011] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Regional cerebral perfusion (RCP) has been shown to provide cerebral circulatory support during Norwood procedure. In our institution, high-flow RCP (HFRCP) from the right innominate artery has been induced to keep sufficient cerebral and somatic oxygen delivery via collateral vessels. We studied the effectiveness of HFRCP to regional cerebral and somatic tissue oxygenation in Norwood stage I palliation. METHODS Seventeen patients, who underwent the Norwood procedure, were separated into two groups: group C (n=6) using low-flow RCP and group H (n=11) using HFRCP (mean flow: 54 vs 92mlkg(-1)min(-1), P<0.0001). The mean duration of RCP was 64±10min (range, 49-86min) under the moderate hypothermia. Chlorpromazine (3.0mgkg(-1)) was given to group H patients before and during RCP to increase RCP flow. The mean radial arterial pressure was kept <50mmHg during RCP. To clarify the effectiveness of HFRCP for cerebral and somatic tissue oxygenation, cerebral regional oxygen saturation (rSO(2)) and systemic venous oxygenation (SvO(2)) during RCP were compared between the two groups. Changes in the lactate level before and after RCP, and changes in the blood urea nitrogen (BUN), creatinine, lactate dehydrogenase (LDH), and creatinine kinase (CK) levels before and after surgery, were also compared between the groups. RESULTS Mean rSO(2) was 82.9±9.0% in group H and 65.9±10.7% in group C (P<0.05). Mean SvO(2) during RCP was 98.2±4.3% in group H and 85.4±9.7% in group C (P<0.01). During RCP, lactate concentration significantly increased in group C compared with that in group H (P<0.001). After surgery, the LDH and CK levels significantly increased in group C compared with that in group H (P<0.05). CONCLUSIONS Our study revealed that HFRCP preserved sufficient cerebral and somatic tissue oxygenation during the Norwood procedure. The reduction of vascular resistance of collateral vessels increased both cerebral and somatic blood flow, resulting in improved tissue oxygen delivery.
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Affiliation(s)
- Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan.
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McKenzie ED, Klysik M, Morales DLS, Heinle JS, Fraser CD, Kovalchin J. Ascending sliding arch aortoplasty: a novel technique for repair of arch hypoplasia. Ann Thorac Surg 2011; 91:805-10. [PMID: 21353003 DOI: 10.1016/j.athoracsur.2010.10.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 10/14/2010] [Accepted: 10/18/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Coarctation of the aorta (CoA) is often associated with clinically significant hypoplasia of the aortic arch. Historically, patch aortoplasty or bypass procedures have been the preferred techniques when arch augmentation is required in children beyond infancy. While safe and effective, these approaches require prosthetic or biologic material without the potential for growth, or normal endothelial and physiologic elastic function. This retrospective study reviews the use of a novel technique, ascending sliding arch aortoplasty, that utilizes viable autologous tissue for repair of arch obstruction in children beyond infancy. METHODS Between April 2002 and January 2007, 8 patients ranging in age from 18 months to 15 years underwent repair of CoA with arch hypoplasia using ascending sliding arch aortoplasty. All patients were approached through median sternotomy, utilizing cardiopulmonary bypass and selective antegrade cerebral perfusion. RESULTS There was no mortality or major morbidity. One toddler had pneumonia, resulting in an increased length of stay. Median duration of hospitalization was 5.8 days, ranging from 3 to 10 days. No patient had evidence of residual obstruction or recurrent CoA at a mean follow-up interval of 36 months. CONCLUSIONS Ascending sliding arch aortoplasty for CoA with arch obstruction in children beyond infancy is a safe technique that can be accomplished without deep hypothermic circulatory arrest. There is no evidence of recurrence at midterm follow-up. Because the augmentation is accomplished with viable autologous aortic tissue, the potential for growth, preserved elasticity and endothelial function, and resistance to infection make this method attractive for use in the young.
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Affiliation(s)
- E Dean McKenzie
- Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA.
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Miyaji K, Miyamoto T, Kohira S, Itatani KI, Tomoyasu T, Inoue N, Ohara K. Regional High-Flow Cerebral Perfusion Improves Both Cerebral and Somatic Tissue Oxygenation in Aortic Arch Repair. Ann Thorac Surg 2010; 90:593-9. [DOI: 10.1016/j.athoracsur.2010.03.113] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 03/24/2010] [Accepted: 03/26/2010] [Indexed: 11/29/2022]
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Hoffman GM, Ghanayem NS. Perioperative neuromonitoring in pediatric cardiac surgery: Techniques and targets. PROGRESS IN PEDIATRIC CARDIOLOGY 2010. [DOI: 10.1016/j.ppedcard.2010.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sasaki T, Tsuda S, Riemer RK, Ramamoorthy C, Reddy VM, Hanley FL. Optimal flow rate for antegrade cerebral perfusion. J Thorac Cardiovasc Surg 2010; 139:530-5; discussion 535. [PMID: 20176202 DOI: 10.1016/j.jtcvs.2009.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 11/24/2009] [Accepted: 12/07/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Antegrade cerebral perfusion is widely used in neonatal heart surgery, yet commonly used flow rates have never been standardized. The objective of this study was to determine the antegrade cerebral perfusion flow rate that most closely matches standard cardiopulmonary bypass conditions. METHODS Nine neonatal piglets underwent deep hypothermic cardiopulmonary bypass at a total body flow of 100 mL/kg/min (baseline). Antegrade cerebral perfusion was conducted via innominate artery cannulation at perfusion rates of 10, 30, and 50 mL/kg/min in random order. Cerebral blood flow was measured using fluorescent microspheres. Regional oxygen saturation and cerebral oxygen extraction were monitored. RESULTS Cerebral blood flow was as follows: baseline, 60 +/- 17 mL/100 g/min; antegrade cerebral perfusion at 50 mL/kg/min, 56 +/- 17 mL/100 g/min; antegrade cerebral perfusion at 30 mL/kg/min, 36 +/- 9 mL/100 g/min; and antegrade cerebral perfusion at 10 mL/kg/min, 13 +/- 6 mL/100 g/min. At an antegrade cerebral perfusion rate of 50 mL/kg/min, cerebral blood flow matched baseline (P = .87), as did regional oxygen saturation (P = .13). Antegrade cerebral perfusion at 30 mL/kg/min provided approximately 60% of baseline cerebral blood flow (P < .002); however, regional oxygen saturation was equal to baseline (P = .93). Antegrade cerebral perfusion at 10 mL/kg/min provided 20% of baseline cerebral blood flow (P < .001) and a lower regional oxygen saturation than baseline (P = .011). Cerebral oxygen extraction at antegrade cerebral perfusion rates of 30 and 50 mL/kg/min was equal to baseline (P = .53, .48) but greater than baseline (P < .0001) at an antegrade cerebral perfusion rate of 10 mL/kg/min. The distributions of cerebral blood flow and regional oxygen saturation were equal in each brain hemisphere at all antegrade cerebral perfusion rates. CONCLUSION Cerebral blood flow increased with antegrade cerebral perfusion rate. At an antegrade cerebral perfusion rate of 50 mL/kg/min, cerebral blood flow was equal to baseline, but regional oxygen saturation and cerebral oxygen extraction trends suggested more oxygenation than baseline. An antegrade cerebral perfusion rate of 30 mL/kg/min provided only 60% of baseline cerebral blood flow, but cerebral oxygen extraction and regional oxygen saturation were equal to baseline. An antegrade cerebral perfusion rate that closely matches standard cardiopulmonary bypass conditions is between 30 and 50 mL/kg/min.
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Affiliation(s)
- Takashi Sasaki
- Stanford University, Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, 300 Pasteur Drive, Falk Rm CV116C, Stanford, CA 94305-5407, USA.
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Abstract
Brain and heart development occur simultaneously in the human fetus. Given the depth and complexity of these shared morphogenetic programs, it is perhaps not surprising that disruption of organogenesis in one organ will impact the development of the other. Newborns with congenital heart disease show a high frequency of acquired focal brain injury on sensitive magnetic resonance imaging studies in the perioperative period. The surprisingly high incidence of white matter injury in these term newborns suggests a unique vulnerability and may be related to a delay in brain development. These abnormalities in brain development identified with MRI in newborns with congenital heart disease might reflect abnormalities in cerebral blood flow while in utero. A complete understanding of the mechanisms of white matter injury in the term newborn with congenital heart disease will require further investigation of the timing, extent, and causes of delayed fetal brain development in the presence of congenital heart disease.
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Affiliation(s)
- Patrick S McQuillen
- Department of Pediatrics, University of California, San Francisco, California, USA
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Zhang H, Cheng P, Hou J, Li L, Liu H, Liu R, Ji B, Luo Y. Regional cerebral perfusion for surgical correction of neonatal aortic arch obstruction. Perfusion 2009; 24:185-9. [PMID: 19759060 DOI: 10.1177/0267659109346661] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
One-stage repair of aortic arch obstruction and associated cardiac anomalies is a surgical challenge in infants.The purpose of the present study is to review the current outcome using regional cerebral perfusion (RCP) during a procedure correcting interrupted aortic arch (IAA) and also isolated aortic coarctation (CoA) and CoA combined with hypoplastic aortic arch (CoA-HyAA) in our center. Between January 2007 and July 2008, 24 infant patients with interrupted aortic arch (IAA) (n=3), isolated aortic coarctation (iCoA) (n=9) and aortic coarctation with hypoplastic aortic arch (CoA-HyAA) (n=12) underwent one-stage surgical correction in our hospital. End-to-end anastomosis was employed in 12 infants (IAA n=3 and iCoA n=9); for the other 12 patients with CoA-HyAA, an end-to-end extended anastomosis was used in 8 cases, end-to-side anastomosis in 2 cases, and composite heterologous pericardial patch in 2 cases. RCP with 40 mL/kg/min through the innominate artery during aortic arch reconstruction was employed for all pediatric patients. One single-dose histidine-ketoglutarate-tryptophan (HTK) solution was used for myocardial protection during CPB. Cardiopulmonary bypass time and aortic cross-clamp time were 165.6±32.4min and 81.7±30.0min, respectively. The mean regional cerebral perfusion time was 31.0±10.6min; lowest nasopharyngeal temperature was 19.1±1.1°C. Operative mortality rate in both groups was 8.3%. Mean follow-up was 10.5±4.8 months. There was no late mortality or postoperative neurologic, renal or hepatic complications. All patients are asymptomatic and are developing normally. One-stage total arch repair using the RCP technique is an excellent method that may minimize neurologic and renal complications. Our surgical strategy for arch anomaly has a low rate of residual and recurrent coarctation when performed in these infants.
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Affiliation(s)
- Hui Zhang
- Department of Pediatric Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Pei Cheng
- Department of Pediatric Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jia Hou
- Department of Pediatric Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lei Li
- Department of Pediatric Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hu Liu
- Department of Pediatric Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ruifang Liu
- Department of Cardiopulmonary Bypass, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi Luo
- Department of Pediatric Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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