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Lu P, Gong X, Gu X, Jiang S, Cao Y, Sun C, Du J, Lei X, Lee SK. Mortality and extrauterine growth restriction of necrotizing enterocolitis in very preterm infants with heart disease: a multi-center cohort study. Eur J Pediatr 2024:10.1007/s00431-024-05599-z. [PMID: 38822834 DOI: 10.1007/s00431-024-05599-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/28/2024] [Accepted: 05/03/2024] [Indexed: 06/03/2024]
Abstract
Congenital heart disease (CHD) and patent ductus arteriosus (PDA) are risk factors of necrotizing enterocolitis (NEC) in infants. However, it is unclear whether the prognosis of NEC is different between very preterm infants (VPIs) with and without heart diseases. This was an observational cohort study that enrolled VPIs (born between 24+0 and 31+6 weeks) admitted to 79 tertiary neonatal intensive care units (NICU) in the Chinese Neonatal Network (CHNN) between 2019 and 2021. The exposure was CHD or isolated PDA, and VPIs with NEC were divided into three groups: complicated with CHD, with isolated PDA, and without heart diseases. The primary outcomes were NEC-related adverse outcomes (death or extrauterine growth restriction (EUGR)). Logistic regression models were used to adjust potential confounders and calculate the odds ratios (ORs) and 95% confidential intervals (CIs) for each outcome. A total of 1335 VPIs with NEC were enrolled in this study, including 65 VPIs with CHD and 406 VPIs with isolated PDA. The VPIs with heart diseases had smaller gestational ages and lower body weights at birth, more antenatal steroids use, and requiring inotrope prior to the onset of NEC. While suffering from NEC, there was no significant increased risks in NEC-related death in VPIs with either CHD (adjusted OR [aOR]: 1.10; 95% CI: 0.41-2.50) or isolated PDA (aOR: 1.25; 95% CI 0.82-1.87), and increased risks in EUGR were identified in either survival VPIs with CHD (aOR: 2.35; 95% CI: 1.31-4.20) or isolated PDA (aOR: 1.53; 95% CI: 1.16-2.01) in survivors. The composite outcome (death or EUGR) was also more often observed in VPIs with either CHD (aOR: 2.07; 95% confidence interval [CI]: 1.20-3.60) or isolated PDA (aOR: 1.51; 95% CI: 1.17-1.94) than that without heart diseases. VPIs with either CHD or isolated PDA were associated with significantly prolonged duration of fasting, extended time to achieve full enteral feeding, and longer ventilation duration and hospitalization duration. Similar characteristics were also seen in VPIs with isolated PDA, with the exception that VPIs with CHD are more likely to undergo surgical intervention and maintain a prolonged fast after NEC. Conclusion: In VPIs with NEC, CHD and isolated PDA are associated with an increased risk in worse outcomes. We recommend that VPIs with cardiac NEC be managed with aggressive treatment and nutrition strategies to prevent EUGR. What is Known: • CHD and PDA are risk factors for NEC in infants, which can lead to adverse outcomes such as death and EUGR. • NEC in infants with heart disease differs clinically from that in infants without heart disease and should be recognized as a separate disease process. What is New: • CHD and isolated PDA are associated with increased risks of EUGR in VPIs with NEC. • Risk factors associated with VPIs with cardiac NEC suggested these patients should be managed with aggressive treatment and nutrition strategies to adverse outcomes.
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Affiliation(s)
- Pei Lu
- Department of Neonatology, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, 355 Luding Road, Putuo District, Shanghai, 200062, China
| | - Xiaohui Gong
- Department of Neonatology, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, 355 Luding Road, Putuo District, Shanghai, 200062, China.
| | - Xinyue Gu
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
| | - Siyuan Jiang
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
- Division of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Yun Cao
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
- Division of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Chengjun Sun
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Juan Du
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
| | - Xiaoping Lei
- Division of Neonatology, Department of Pediatrics, the Affiliated Hospital, Southwest Medical University, 8 Kangcheng Road, Luzhou, Sichuan, China.
| | - Shoo K Lee
- Maternal-Infant Care Research Centre, Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Mills KI, Kim JH, Fogg K, Goldshtrom N, Graham EM, Kataria-Hale J, Osborne SW, Figueroa M. Nutritional Considerations for the Neonate With Congenital Heart Disease. Pediatrics 2022; 150:189883. [PMID: 36317972 DOI: 10.1542/peds.2022-056415g] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
The importance of nutrition in managing critically ill infants with congenital heart disease (CHD) is foundational to optimizing short- and long-term health outcomes. Growth failure and malnutrition are common in infants with CHD. The etiology of growth failure in this population is often multifactorial and may be related to altered metabolic demands, compromised blood flow to the intestine leading to nutrient malabsorption, cellular hypoxia, inadequate energy intake, and poor oral-motor skills. A dearth of high-quality studies and gaps in previously published guidelines have led to wide variability in nutrition practices that are locally driven. This review provides recommendations from the nutrition subgroup of the Neonatal Cardiac Care Collaborative for best evidence-based practices in the provision of nutritional support in infants with CHD. The review of evidence and recommendations focused on 6 predefined areas of clinical care for a target population of infants <6 months with CHD admitted to the ICU or inpatient ward. These areas include energy needs, nutrient requirements, enteral nutrition, feeding practice, parenteral nutrition, and outcomes. Future progress will be directed at quality improvement efforts to optimize perioperative nutrition management with an increasing emphasis on individualized care based on nutritional status, cardiorespiratory physiology, state of illness, and other vulnerabilities.
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Affiliation(s)
- Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts.,Contributed equally as co-first authors
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Contributed equally as co-first authors
| | - Kristi Fogg
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nimrod Goldshtrom
- Division of Neonatology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Eric M Graham
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Jasmeet Kataria-Hale
- Division of Neonatology, Department of Pediatrics, Mission Children's Hospital, Asheville, North Carolina
| | - Scott W Osborne
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mayte Figueroa
- Division of Cardiology and Critical Care, Department of Pediatrics, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
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Roychaudhuri S, Grewal G, Vijayashankar SS, Lavoie P, Maheshwari A. Necrotizing Enterocolitis Associated with Congenital Heart Disease-A Review Article. NEWBORN (CLARKSVILLE, MD.) 2022; 1:170-176. [PMID: 36864827 PMCID: PMC9976612 DOI: 10.5005/jp-journals-11002-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Necrotizing enterocolitis (NEC) is a relatively rare but devastating entity associated classically with the preterm cohort in the neonatal intensive care unit. Preterm and term babies with congenital heart disease are at risk of a number of comorbidities because of the hemodynamic derangements due to a structurally abnormal heart and the corrective procedures adopted. Necrotizing enterocolitis is one of the dreaded complications associated with this cohort and impacts the course of these babies in the hospital in a major way. A large majority of term babies with NEC are in the backdrop of a significant congenital cardiac lesion. This review article summarizes the literature and elaborates this entity including its specific features, risk factors associated with its causality, histopathology and related aspects of hemodynamics, and feeding in this vulnerable population. It also provides insight into modifiable risk factors and early markers of detection of gut necrosis to facilitate prevention and early detection. It highlights the subtle but definite difference in outcome variables to help physicians enable the parents of babies with heart disease to develop a better understanding of the entity and its expected course while counseling.
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Affiliation(s)
- Sriya Roychaudhuri
- Department of Pediatrics, Division of Neonatology, BC Women’s Hospital, Vancouver, Canada
| | - Gurpreet Grewal
- Department of Neonatal-Perinatal Medicine BC Women’s Hospital and Health Centre, British Columbia, Vancouver, Canada
| | | | - Pascal Lavoie
- Department of Neonatal-Perinatal Medicine BC Women’s Hospital and Health Centre, British Columbia, Vancouver, Canada
| | - Akhil Maheshwari
- Department of Neonatal-Perinatal Medicine, Global Newborn Society, Baltimore, Maryland, United States of America
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Watson JD, Urban TT, Tong SS, Zenge J, Khailova L, Wischmeyer PE, Davidson JA. Immediate Post-operative Enterocyte Injury, as Determined by Increased Circulating Intestinal Fatty Acid Binding Protein, Is Associated With Subsequent Development of Necrotizing Enterocolitis After Infant Cardiothoracic Surgery. Front Pediatr 2020; 8:267. [PMID: 32537446 PMCID: PMC7267022 DOI: 10.3389/fped.2020.00267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/28/2020] [Indexed: 12/13/2022] Open
Abstract
Objectives: 1 Measure serial serum intestinal fatty acid binding protein levels in infants undergoing cardiac surgery with cardiopulmonary bypass to evaluate for evidence of early post-operative enterocyte injury. 2 Determine the association between immediate post-operative circulating intestinal fatty acid binding protein levels and subsequent development of necrotizing enterocolitis. Design: Observational cohort study. Intestinal fatty acid binding protein was measured pre-operatively, at rewarming, and at 6 and 24 h post-operatively. Percent of goal enteral kilocalories on post-operative day 5 and episodes of necrotizing enterocolitis were determined. Multivariable analysis assessed for factors independently associated with clinical feeding outcomes and suspected/definite necrotizing enterocolitis. Setting: Quaternary free-standing children's hospital pediatric cardiac intensive care unit. Patients: 103 infants <120 days of age undergoing cardiothoracic surgery with cardiopulmonary bypass. Interventions: None. Results: Median pre-operative intestinal fatty acid binding protein level was 3.93 ng/ml (range 0.24-51.32). Intestinal fatty acid binding protein levels rose significantly at rewarming (6.35 ng/ml; range 0.54-56.97; p = 0.008), continued to rise slightly by 6 h (6.57 ng/ml; range 0.75-112.04; p = 0.016), then decreased by 24 h (2.79 ng/ml; range 0.03-81.74; p < 0.0001). Sixteen subjects (15.7%) developed modified Bell criteria Stage 1 necrotizing enterocolitis and 9 subjects (8.8%) developed Stage 2 necrotizing enterocolitis. Infants who developed necrotizing enterocolitis demonstrated a significantly higher distribution of intestinal fatty acid binding protein levels at both 6 h (p = 0.005) and 24 h (p = 0.005) post-operatively. On multivariable analysis, intestinal fatty acid binding protein was not associated with percentage of goal enteral kilocalories delivered on post-operative day 5. Higher intestinal fatty acid binding protein was independently associated with subsequent development of suspected/definite necrotizing enterocolitis (4% increase in odds of developing necrotizing enterocolitis for each unit increase in intestinal fatty acid binding protein; p = 0.0015). Conclusions: Intestinal fatty acid binding protein levels rise following infant cardiopulmonary bypass, indicating early post-operative enterocyte injury. Intestinal fatty acid binding protein was not associated with percent of goal enteral nutrition achieved on post-operative day 5, likely due to protocolized feeding advancement based on clinically observable factors. Higher intestinal fatty acid binding protein at 6 h post-operatively was independently associated with subsequent development of necrotizing enterocolitis and may help identify patients at risk for this important complication.
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Affiliation(s)
- John D Watson
- Department of Pediatrics, University of Colorado, Aurora, CO, United States
| | - Tracy T Urban
- Research Institute, Children's Hospital Colorado, Aurora, CO, United States
| | - Suhong S Tong
- Department of Biostatistics, Children's Hospital Colorado/University of Colorado, Aurora, CO, United States
| | - Jeanne Zenge
- Department of Pediatrics, University of Colorado, Aurora, CO, United States
| | - Ludmilla Khailova
- Department of Pediatrics, University of Colorado, Aurora, CO, United States
| | - Paul E Wischmeyer
- Duke University Department of Anesthesiology, Durham, NC, United States
| | - Jesse A Davidson
- Department of Pediatrics, University of Colorado, Aurora, CO, United States
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Affiliation(s)
- Scott M Bradley
- Section of Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC.
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Mirabile C, Mazzola A, Valeanu L, Lopez-Lopez V, Barbanti C, Biselli C, Hennequin C, Malekzadeh-Milani S, Bojan M. Postoperative B-type natriuretic peptide monitoring for the assessment of the magnitude of shunting through Blalock-Taussig anastomoses. Int J Cardiol 2017; 249:151-155. [PMID: 28912041 DOI: 10.1016/j.ijcard.2017.08.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 08/11/2017] [Accepted: 08/30/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Modified Blalock-Taussig shunt (MBTS) is the most common palliative operation performed in patients with complex cardiac defects. Postoperative morbidity and mortality rates are high, mainly due to shunt thrombosis and over-shunting. Over-shunting may be difficult to identify postoperatively based on conventional criteria. Since plasma B-type natriuretic peptide (BNP) concentrations correlate with the magnitude of shunting in various left-to-right shunt cardiac defects, we investigated its ability to identify postoperative MBTS over-shunting. METHODS AND RESULTS This retrospective, observational study included 42 consecutive patients (median age 9.50days, IQR: 6.00-58.25) undergoing MBTS for obstruction of the pulmonary blood flow at a tertiary referral pediatric cardiac center. The BNP threshold concentrations which accurately predicted outcome and MBTS over-shunting were derived using the ROC methodology. 443 BNP concentrations were analysed. The presence of atrio-ventricular valve regurgitation was the most important component of overall variance (72.75%). In 34 patients without regurgitation, BNP concentrations were predictive of a duration of mechanical ventilation >8days and of intensive care stay >11days, with ROC areas of 0.655 [0.597-0.719], 0.650 [0.589-0.711], a negative predictive value for the >1035pgmL-1 threshold of 0.93 and 0.96 respectively. SaO2 was less accurate for the prediction of both outcomes. In patients in whom the pulmonary flow was entirely MBTS-supplied, a BNP concentrations >1052pgmL-1 was predictive of a pulmonary-to-systemic ratio>2. CONCLUSION In MBTS patients without atrio-ventricular valve regurgitation, maintaining BNP below 1000pgmL-1 may represent a therapeutic target to avoid over-shunting.
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Affiliation(s)
- Cristian Mirabile
- Department of Anesthesiology and Critical Care, Necker-Enfants Malades University Hospital, Paris, France
| | - Alessandra Mazzola
- Department of Pediatric Cardiac Surgery, Necker-Enfants Malades University Hospital, Paris, France
| | - Liana Valeanu
- Department of Cardiac Anesthesiology and Critical Care, Emergency Institute for Cardio-Vascular Diseases, Bucharest, Romania
| | - Vanessa Lopez-Lopez
- Department of Anesthesiology and Critical Care, Necker-Enfants Malades University Hospital, Paris, France
| | - Claudio Barbanti
- Department of Anesthesiology and Critical Care, Necker-Enfants Malades University Hospital, Paris, France
| | - Camilla Biselli
- Department of Anesthesiology and Critical Care, Necker-Enfants Malades University Hospital, Paris, France
| | - Carole Hennequin
- Department of Biochemistry, Necker-Enfants Malades University Hospital, Paris, France
| | - Sophie Malekzadeh-Milani
- Department of Pediatric Cardiology, M3C Reference Center for Complex Congenital Heart Diseases, Necker-Enfants Malades University Hospital, Paris, France
| | - Mirela Bojan
- Department of Anesthesiology and Critical Care, Necker-Enfants Malades University Hospital, Paris, France.
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Abstract
OBJECTIVES The objectives of this review are to discuss the challenges of delivering adequate nutrition to children with congenital heart disease, including pre- and postoperative factors and the role of enteral and parenteral nutrition, as well as the evidence supporting current practices. DATA SOURCE MEDLINE and PubMed. CONCLUSION Providing adequate nutritional support is paramount for critically ill infants with congenital heart disease, a population at particular risk for malnutrition. Improved nutritional support has been associated with increased survival and reduction in overall morbidity. Further gains can be achieved by creating a clinical culture that emphasizes optimal perioperative nutritional support. Additional research is required to identify the specific nutrient composition, optimal mode, and timing of delivery to maximize clinical benefit.
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8
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Mesenteric near-infrared spectroscopy and risk of gastrointestinal complications in infants undergoing surgery for congenital heart disease. Cardiol Young 2016; 26:772-80. [PMID: 26343176 DOI: 10.1017/s1047951115001365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We hypothesised that lower mesenteric near-infrared spectroscopy values would be associated with a greater incidence of gastrointestinal complications in children weighing <10 kg who were recovering from cardiac surgery. We evaluated mesenteric near-infrared spectroscopy, central venous oxygen saturation, and arterial blood gases for 48 hours post-operatively. Enteral feeding intake, gastrointestinal complications, and markers of organ dysfunction were monitored for 7 days. A total of 50 children, with median age of 16.7 (3.2-31.6) weeks, were studied. On admission, the average mesenteric near-infrared spectroscopy value was 71±18%, and the systemic oxygen saturation was 93±7.5%. Lower admission mesenteric near-infrared spectroscopy correlated with longer time to establish enteral feeds (r=-0.58, p<0.01) and shorter duration of feeds at 7 days (r=0.48, p<0.01). Children with gastrointestinal complications had significantly lower admission mesenteric near-infrared spectroscopy (58±18% versus 73±17%, p=0.01) and higher mesenteric arteriovenous difference of oxygen at admission [39 (23-47) % versus 19 (4-27) %, p=0.02]. Based on multiple logistic regression, admission mesenteric near-infrared spectroscopy was independently associated with gastrointestinal complications (Odds ratio, 0.95; 95% confidence interval, 0.93-0.97; p=0.03). Admission mesenteric near-infrared spectroscopy showed an area under the receiver operating characteristic curve of 0.76 to identify children who developed gastrointestinal complications, with a suggested cut-off value of 72% (78% sensitivity, 68% specificity). In this pilot study, we conclude that admission mesenteric near-infrared spectroscopy is associated with gastrointestinal complications and enteral feeding tolerance in children after cardiac surgery.
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Graziano K, Islam S, Dasgupta R, Lopez ME, Austin M, Chen LE, Goldin A, Downard CD, Renaud E, Abdullah F. Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review. J Pediatr Surg 2015. [PMID: 26205079 DOI: 10.1016/j.jpedsurg.2015.06.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Patients with malrotation, or an intestinal rotation abnormality (IRA), can experience serious adverse events. Increasingly, asymptomatic patients are being diagnosed with malrotation incidentally. Patients with symptomatic malrotation require surgery in an urgent or semiurgent manner to address their symptoms. The treatment of asymptomatic or incidentally discovered malrotation remains controversial. METHODS Data were compiled from a broad search of Medline, Cochrane, Embase and Web of Science from January 1980 through January 2013 for five questions regarding asymptomatic malrotation. RESULTS There is minimal evidence to support screening asymptomatic patients. Consideration may be given to operate on asymptomatic patients who are younger in age, while observation may be appropriate in the older patient. If reliably diagnosed, atypical malrotation with a broad-based mesentery and malposition of the duodenum can be observed. Regarding diagnostic imaging, the standard of care for diagnosis remains the upper gastrointestinal contrast study (UGI), ultrasound may be useful for screening. A laparoscopic approach is safe for diagnosis and treatment of rotational abnormalities. Laparoscopy can aid in determining whether a patient has true malrotation with a narrow mesenteric stalk, has nonrotation and minimal risk for volvulus, or has atypical anatomy with malposition of the duodenum. It is reasonable to delay Ladd procedures until after palliation on patients with severe congenital heart disease. Observation can be considered with extensive education for family and caregivers and close clinical follow-up. CONCLUSIONS There is a lack of quality data to guide the management of patients with asymptomatic malrotation. Multicenter and prospective data should be collected to better assess the risk profile for this complex group of patients. A multidisciplinary approach involving surgery, cardiology, critical care and the patient's caregivers can help guide a watchful waiting management plan in individual cases.
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Affiliation(s)
- Kathleen Graziano
- Division of Pediatric General Surgery, Phoenix Children's Hospital, Phoenix, AZ.
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida, Gainesville, FL
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH
| | - Monica E Lopez
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Mary Austin
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center; Department of Pediatric Surgery, University of Texas Medical School, Houston, TX
| | - Li Ern Chen
- Department of Surgery, Baylor University Medical Center, Dallas, TX
| | - Adam Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital; Department of Surgery, University of Washington, Seattle, WA
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr, MD; Department of Surgery, University of Louisville, Louisville, KY
| | - Elizabeth Renaud
- Division of Pediatric Surgery, Department of Surgery, Albany Medical Center, Albany, NY
| | - Fizan Abdullah
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Ultrasound assessment of mesenteric blood flow in neonates with hypoplastic left heart before and after hybrid palliation. Cardiol Young 2015; 25:1074-9. [PMID: 25216030 DOI: 10.1017/s1047951114001607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Altered mesenteric perfusion may be a contributor to the development of necrotising enterocolitis in patients with hypoplastic left heart syndrome. The goal of this study was to document mesenteric flow patterns in patients with hypoplastic left heart syndrome pre- and post-hybrid procedure. METHODS A prospective study on all patients with hypoplatic left heart syndrome undergoing the hybrid procedure was conducted. Doppler ultrasound analysis of the coeliac and superior mesenteric artery was performed. RESULTS A total of 13 patients were evaluated. There was a significant difference in the coeliac artery effective velocity-time intergral pre- and post-hybrid procedure (8.69±3.84 versus 12.51±4.95 cm, respectively). There were significant differences in the superior mesenteric artery antegrade velocity-time integral pre- and post-hybrid procedure (6.86±2.45 versus 10.52±2.64 cm, respectively) and superior mesenteric artery effective velocity-time integral pre- and post-hybrid procedure (6.22±2.68 versus 9.73±2.73 cm, respectively). There were no significant differences between the coeliac and superior mesenteric artery Doppler indices in the pre-hybrid procedure; there were, however, significant differences in the post-hybrid procedure between coeliac and superior mesenteric artery antegrade velocity-time integral (13.8 2±5.60 versus 10.52±2.64 cm, respectively) and effective velocity-time integral (13.04±4.71 versus 9.73±2.73 cm, respectively). CONCLUSION Doppler mesenteric indices of perfusion improve in patients with hypoplastic left heart syndrome after the hybrid procedure; however, there appears to be preferential flow to the coeliac artery versus the superior mesenteric artery in these patients post-procedure.
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Abnormal abdominal aorta hemodynamics are associated with necrotizing enterocolitis in infants with hypoplastic left heart syndrome. Pediatr Cardiol 2014; 35:616-21. [PMID: 24154504 PMCID: PMC3959578 DOI: 10.1007/s00246-013-0828-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 10/03/2013] [Indexed: 01/24/2023]
Abstract
The risk of necrotizing enterocolitis (NEC) in association with congenital heart disease is highest in patients with hypoplastic left heart syndrome (HLHS). Within the HLHS population, however, risk factors for NEC remain debated. We hypothesized that some infants with HLHS have vascular changes that contribute to gut hypoperfusion independent of diastolic runoff and low cardiac output. We analyzed the abdominal aorta pulsatility index and right-ventricular function on routine preoperative and postoperative echocardiograms for all infants who underwent stage I palliation for HLHS from January 2007 to January 2012. The echocardiography findings and clinical course were compared between those with and those without an episode of NEC. Of the 61 cases reviewed, 11 (18 %) developed NEC during a mean follow-up of 3.8 ± 1.3 years. Those with NEC had a lower abdominal aorta pulsatility index compared with those without NEC both on stage I preoperative (3.38 ± 0.15 vs. 3.89 ± 0.09, p < 0.05) and postoperative echocardiograms (2.21 ± 0.28 vs. 3.05 ± 0.78, p = 0.01) despite similar ventricular function and operative risk. Abdominal aorta Doppler pulsations are lower in patients with HLHS whose clinical course is complicated by NEC. This finding suggests that the systemic vasculature in a subset of neonates with HLHS may be inherently abnormal. Further investigation is warranted to determine if this is secondary to structural changes in the mesenteric and/or systemic vasculature.
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Toms R, Jackson KW, Dabal RJ, Reebals CH, Alten JA. Preoperative Trophic Feeds in Neonates with Hypoplastic Left Heart Syndrome. CONGENIT HEART DIS 2014; 10:36-42. [DOI: 10.1111/chd.12177] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Rune Toms
- Department of Pediatrics; Division of Critical Care; Section of Cardiovascular Intensive Care; University of Alabama at Birmingham; Birmingham Ala USA
- Department of Pediatrics; Division of Neonatology; University of Alabama at Birmingham; Birmingham Ala USA
| | - Kimberly W. Jackson
- Department of Pediatrics; Division of Critical Care; Section of Cardiovascular Intensive Care; University of Alabama at Birmingham; Birmingham Ala USA
| | - Robert J. Dabal
- Department of Surgery; Division of Cardiothoracic Surgery; University of Alabama at Birmingham; Birmingham Ala USA
| | - Cristina H. Reebals
- Department of Pediatrics; Division of Neonatology; University of Alabama at Birmingham; Birmingham Ala USA
| | - Jeffrey A. Alten
- Department of Pediatrics; Division of Critical Care; Section of Cardiovascular Intensive Care; University of Alabama at Birmingham; Birmingham Ala USA
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Abstract
OBJECTIVE Necrotising enterocolitis is a rare, though catastrophic complication that may occur in term newborns with congenital heart disease. There is considerable controversy regarding the factors that lead to necrotising enterocolitis in this population. We sought to determine the incidence of necrotising enterocolitis among term and near-term newborns with congenital heart disease, focusing on the relationship of enteral feeding to this complication. METHODS In this retrospective study, we identified the incidence of necrotising enterocolitis among 1551 newborns admitted to our cardiac intensive care unit between July 1, 2002 and July 1, 2010. In order to understand the impact of enteral feeding upon the development of necrotising enterocolitis, we undertook a nested 2:1 matched case-control analysis to compare feeding patterns in an age- and lesion-matched control population. RESULTS Necrotising enterocolitis developed in 45 term or near-term infants (3%). The majority of these cases, 27 (60%), occurred in the post-operative period after the introduction of enteral feeds. This subgroup was used for matched analysis. There were no differences in enteral feeding patterns among the patients who developed necrotising enterocolitis and their matched controls. The overall mortality rate for patients who developed necrotising enterocolitis was 24.4% (11 out of 45). CONCLUSIONS Despite numerous advances in the care of infants with congenital heart disease, necrotising enterocolitis remains a significant source of morbidity and mortality. In these infants, there is no clear relationship between enteral feeding patterns and the development of necrotising enterocolitis in the post-operative period. The benefits of graduated feeding advancements to avoid the development of necrotising enterocolitis remain unproven.
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Cozzi C, Stines J, Luce WA, Hayes J, Cheatham JP, Galantowicz M, Cua CL. Diastolic flow parameters are not sensitive in predicting necrotizing enterocolitis in patients undergoing hybrid procedure. CONGENIT HEART DIS 2012; 8:234-9. [PMID: 23095659 DOI: 10.1111/chd.12017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a significant cause of morbidity and mortality in neonates with complex single-ventricle anatomy undergoing stage I palliation. Hybrid approach is another option for initial single-ventricle palliation. The goal of this study was to determine if there were differences in echocardiographic indices between patients undergoing the hybrid procedure who developed NEC vs. those that did not develop NEC. METHODS Retrospective chart review was performed on patients who underwent the hybrid procedure. Patients were included if an echocardiogram with adequate Doppler tracings through the patent ductus arteriosus stent was available. Echocardiographic indices measured included antegrade velocity-time integral (VTI), retrograde VTI, effective VTI, VTI regurgitant fraction, VTI retrograde/VTI antegrade ratio, calculated cardiac output, peak antegrade velocity through the ductal stent, retrograde/antegrade time ratio, and percent regurgitant time. Indices were compared in patients who developed NEC (NEC Group) and those who did not develop NEC (No NEC Group). NEC was defined as a Bell Stage ≥2. RESULTS Sixty-nine patients met inclusion criteria. Eight of the 69 patients developed NEC. There was no significant difference between the NEC and No NEC Group for antegrade VTI (10.4 ± 3.2 cm vs. 12.7 ± 4.4 cm), retrograde VTI (5.3 ± 1.5 cm vs. 6.1 ± 2.2 cm), effective VTI (5.1 ± 2.9 cm vs. 6.6 ± 3.3 cm), VTI regurgitant fraction (53.6 ± 14.7% vs. 49.7 ± 13.6%), and VTI retrograde/VTI antegrade ratio (0.54 ± 0.15 vs.0.50 ± 0.14). Cardiac output (4.2 ± 1.4 L/min/m(2) vs. 4.8 ± 1.8 L/min/m(2) ) and peak velocity (117.5 ± 28.9 cm/s and 142.4 ± 42.6 cm/s) were also not different between the NEC and No NEC Groups. Furthermore, retrograde/antegrade time ratios (1.6 ± 0.2 vs. 1.7 ± 0.3) and percent retrograde time (60.6 ± 3.0% vs. 62.0 ± 4.0%) were not different between the NEC and No NEC Groups. CONCLUSION Echocardiographic indices were not sensitive in determining the development of NEC in patients undergoing the hybrid procedure. Larger studies with more sensitive imaging techniques are required to help risk stratify NEC in this complex patient population.
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Affiliation(s)
- Corin Cozzi
- Section of Perinatology, Nationwide Children's Hospital, Columbus, Ohio 43205, USA
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Villa CR, Marino BS, Jacobs JP, Cooper DS. Intensive Care and Perioperative Management of Neonates With Functionally Univentricular Hearts. World J Pediatr Congenit Heart Surg 2012; 3:359-63. [DOI: 10.1177/2150135111433473] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Chet R. Villa
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Bradley S. Marino
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Jeffrey P. Jacobs
- The Congenital Heart Institute of Florida (CHIF), Division of Thoracic and Cardiovascular Surgery, All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates, Saint Petersburg and Tampa, FL, USA
| | - David S. Cooper
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
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Abstract
PURPOSE OF REVIEW Adequate enteral nutrition and growth are vital to recovery and survival of infants following palliation for univentricular hearts. This group of patients experiences frequent feeding complications that may impede adequate delivery of enteral nutrition. This review presents the most recent data related to feeding practices, growth patterns and outcomes. It also explores management strategies for delivering enteral nutrition safely and effectively to this high-risk group of infants. RECENT FINDINGS Infants following palliation for single ventricle physiology have persistent growth failure until at least 14 months of life. Greater daily caloric intake attenuates this growth failure. Persistent growth failure is associated with increased mortality following cardiac surgery. Management of enteral nutrition varies widely both pre and postoperatively. Data suggest that standardizing feeding practices improves delivery of enteral nutrition and decreases feeding complications. Evidence-based international feeding guidelines do not exist. SUMMARY Delivery of adequate nutrition in infants with single ventricle physiology is essential to improve outcomes but is often difficult to achieve. Evidence-based feeding guideline development is crucial to improve outcomes in this group of patients.
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Comparison of gastrointestinal morbidity after Norwood and hybrid palliation for complex heart defects. Pediatr Cardiol 2011; 32:391-8. [PMID: 21188371 DOI: 10.1007/s00246-010-9864-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 12/07/2010] [Indexed: 10/18/2022]
Abstract
This study aimed to compare the incidence of gastrointestinal complications among infants with single-ventricle heart defects after three first-stage palliation strategies: Norwood-modified Blalock-Taussig shunt (mBTS), Norwood right ventricle-to-pulmonary artery conduit (Sano), and hybrid procedures. A retrospective chart review was performed in a pediatric cardiac intensive care unit at a tertiary care medical center. The subjects were 32 neonates who had undergone single-ventricle palliation including 13 Norwood-mBTS, 11 Sano, and 8 hybrid procedures. The measurements included baseline as well as pre- and postoperative patient characteristics. The primary outcome was postoperative intraabdominal complications, and the secondary outcomes were feeding intolerance and necrotizing enterocolitis (NEC). Intraabdominal complications occurred for 34%, feeding intolerance for 13%, and NEC for 13% of the patients. The hybrid patients had a higher incidence of intraabdominal complications (75%) than the Norwood-mBTS (31%) or Sano (9%) patients (P = 0.01). The relative risk for intraabdominal complications in the hybrid group was 3.6 (95% confidence interval [CI], 1.5-8.7). In the multivariate analysis, the hybrid procedure remained an independent predictor of intraabdominal complications (hazard ratio, 8.4; 95% CI, 2.0-34.5). The hybrid, Norwood-mBTS, and Sano patients did not differ significantly in terms of feeding intolerance (25, 15, and 0%, respectively; P = 0.25) or NEC (25, 8, and 9%; P = 0.46). Gastrointestinal morbidity was common regardless of the palliative approach, although the hybrid patients had the highest incidence of intraabdominal complications. This supports the need for caution in using enteral nutrition with all single-ventricle patients, including the hybrid population. Patients undergoing the hybrid procedure may benefit from implementation of standardized feeding protocols.
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Johnson JN, Ansong AK, Li JS, Xu M, Gorentz J, Hehir DA, del Castillo SL, Lai WW, Uzark K, Pasquali SK. Celiac artery flow pattern in infants with single right ventricle following the Norwood procedure with a modified Blalock-Taussig or right ventricle to pulmonary artery shunt. Pediatr Cardiol 2011; 32:479-86. [PMID: 21331516 PMCID: PMC3139997 DOI: 10.1007/s00246-011-9906-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 01/31/2011] [Indexed: 01/24/2023]
Abstract
A potential advantage of the right ventricle to pulmonary artery versus modified Blalock-Taussig shunt in patients undergoing the Norwood procedure is limitation of diastolic runoff from the systemic to pulmonary circulation. We evaluated mesenteric flow patterns and gastrointestinal outcomes following the Norwood procedure associated with either shunt type. Patients randomized to a right ventricle to pulmonary artery versus modified Blalock-Taussig shunt in the Pediatric Heart Network Single Ventricle Reconstruction Trial at centers participating in this ancillary study were eligible for inclusion; those with active necrotizing enterocolitis, sepsis, or end-organ dysfunction were excluded. Celiac artery flow characteristics and gastrointestinal outcomes were collected at discharge. Forty-four patients (five centers) were included. Median age at surgery was 5 days [interquartile range (IQR) = 4-8 days]. Median celiac artery resistive index (an indicator of resistance to perfusion) was higher in the modified Blalock-Taussig shunt group (n = 19) versus the right ventricle to pulmonary artery shunt group (n = 25) [1.00 (IQR = 0.84-1.14) vs. 0.82 (IQR = 0.74-1.00), p = 0.02]. There was no difference in interstage weight gain, necrotizing enterocolitis, or feeding intolerance episodes between the groups. The celiac artery resistive index was higher in patients with the modified Blalock-Taussig shunt versus the right ventricle to pulmonary artery shunt but was not associated with measured gastrointestinal outcomes.
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Affiliation(s)
- Jason N. Johnson
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Annette K. Ansong
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Jennifer S. Li
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Mingfen Xu
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Jessica Gorentz
- Division of Pediatric Cardiology and Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - David A. Hehir
- Division of Pediatric Cardiology and Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Wisconsin, Milwaukee, WI, USA
| | - Sylvia L. del Castillo
- Division of Critical Care Medicine, Departments of Anesthesiology Critical Care Medicine and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Wyman W. Lai
- Division of Pediatric Cardiology, Columbia College of Physicians and Surgeons, New York, NY, USA
| | - Karen Uzark
- Division of Pediatric Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Sara K. Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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Golbus JR, Wojcik BM, Charpie JR, Hirsch JC. Feeding complications in hypoplastic left heart syndrome after the Norwood procedure: a systematic review of the literature. Pediatr Cardiol 2011; 32:539-52. [PMID: 21336978 DOI: 10.1007/s00246-011-9907-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 01/31/2011] [Indexed: 11/25/2022]
Abstract
Gastrointestinal and feeding complications after the Norwood procedure in infants with hypoplastic left heart syndrome increases morbidity and mortality. These problems are the result of intraoperative challenges, shunt-dependent physiology, and the absence of best-practice guidelines. In response, a systematic review of feeding-related complications and management strategies was performed. A literature search from 1950 to March 2010 identified 21 primary research articles and 4 reviews. Dysphagia, necrotizing enterocolitis (NEC), and poor nutritional status are significant feeding-related complications. Three studies directly compared the modified Blalock-Taussig shunt with the right ventricle-to-pulmonary artery conduit (RV-PA). Patients palliated with either shunt had impaired mesenteric blood flow. Mortality did not differ between shunt types. Three studies demonstrated improved outcomes, e.g., increased survival, decreased incidence of NEC, and decreased median time to recommended daily allowance of calories, with a postoperative feeding algorithm. Two studies showed increased survival between stage I and II surgical palliation after implementation of a home-monitoring system consisting of daily weight and systemic oxygen saturation measurements. The RV-PA shunt does not significantly alter mortality or increase mesenteric blood flow. A postoperative feeding algorithm and a home-monitoring system may improve outcomes and decrease average hospital length of stay (LOS). Additional studies are needed to determine which interventions, as part of a standardized protocol, improve survival and decrease complications.
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Affiliation(s)
- Jessica R Golbus
- University of Michigan Medical School, 1301 Catherine Road, Ann Arbor, MI 48109-5864, USA
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Classic Norwood versus Sano modification versus hybrid approach: necrotizing enterocolitis or no necrotizing enterocolitis? Pediatr Crit Care Med 2011; 12:109-10. [PMID: 21209574 DOI: 10.1097/pcc.0b013e3181e289fb] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reducing the incidence of necrotizing enterocolitis in neonates with hypoplastic left heart syndrome with the introduction of an enteral feed protocol. Pediatr Crit Care Med 2010; 11:373-7. [PMID: 19838139 DOI: 10.1097/pcc.0b013e3181c01475] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Neonates with hypoplastic left heart syndrome are prone to gastrointestinal complications, including necrotizing enterocolitis, during initiation or advancement of enteral feeds. A feeding protocol was developed to standardize practice across a multidisciplinary team. The purpose of this study was to examine the impact of a standardized feeding protocol on the incidence of necrotizing enterocolitis and overall postoperative gastrointestinal morbidity. DESIGN Retrospective case-control study. SETTING Cardiothoracic intensive care unit of a tertiary care children's hospital. PATIENTS Ninety-eight neonates with hypoplastic left heart syndrome admitted to the cardiothoracic intensive care unit after first-stage palliation. INTERVENTION A retrospective chart review was performed. Two groups were analyzed: the preprotocol group (n = 52) was examined from January 2000 through December 31, 2001, and the postprotocol group (n = 46) from February 2002 through December 31, 2003. MEASUREMENTS AND MAIN RESULTS The incidence of suspected or diagnosed necrotizing enterocolitis as defined by the modified Bell staging criteria was recorded. Data were also collected regarding postoperative day of enteral feed initiation, postoperative day full feeds attained, and postoperative hospital length of stay. Necrotizing enterocolitis was detected in 14 preprotocol (27%) and three postprotocol (6.5%) patients (p < .01). Enteral feeds were initiated later in the postprotocol group (7.5 vs. 5.5 days, p < .001), and number of days to full feeds was also later in the postprotocol group (7 vs. 4 days, p = .02). Hospital length of stay tended to be shorter in the postprotocol group (21.5 vs. 28 days, p = .25). CONCLUSION Measures directed at reducing the incidence of necrotizing enterocolitis may reduce morbidity in neonates with hypoplastic left heart syndrome and reduce cost by decreasing hospital length of stay. A standardized feeding protocol instituted to address these problems likely contributed to reducing the incidence of necrotizing enterocolitis in this high-risk population.
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Torres A. To (enterally) feed or not to feed (the infant with hypoplastic left heart syndrome) is no longer the question. Pediatr Crit Care Med 2010; 11:431-2. [PMID: 20453619 DOI: 10.1097/pcc.0b013e3181ce6cb5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Raja SG. Right ventricle to pulmonary artery shunt modification of the Norwood procedure. Expert Rev Cardiovasc Ther 2010; 8:675-684. [DOI: 10.1586/erc.10.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Abstract
BACKGROUND Infants with hypoplastic left heart syndrome (HLHS) experience a high incidence of growth failure in the postoperative period following stage I palliation. Because of an increased risk of necrotizing enterocolitis in this population, clinicians may be reluctant to initiate early enteral feedings. Published guidelines for initiating and advancing enteral feedings in this population are limited. OBJECTIVE To test the safety and efficacy of an enteral feeding algorithm in infants with HLHS following stage I palliation. DESIGN Single-center, prospective case series with historical comparisons. SETTING Pediatric cardiovascular intensive care unit in tertiary care children's hospital. PATIENTS The study group consisted of consecutive patients > or =35 wks gestational age and weight > or =2 kg admitted to our cardiac intensive care unit over an 18-month period following stage I palliation of HLHS (n = 36). Excluded were nonsurvivors, patients supported on extracorporeal membrane oxygenation or those with a history of NEC or fetal intervention. These data were compared with a similar cohort of patients admitted to the cardiac intensive care unit over an 18-month period before the implementation of the feeding algorithm (n = 27). INTERVENTION A feeding algorithm was implemented in the study group in the postoperative period for initiation and advancement of enteral nutrition. MEASUREMENTS AND MAIN RESULTS The median duration of total parenteral nutrition was significantly higher in the control group (116 vs. 51 hrs; p = 0.03) compared with the study group. The median time to achieve recommended daily allowance of calories defined as 108 kcal/kg per day was significantly reduced in the study group (9 vs. 13 days; p = 0.01). Despite the rapid advancement of enteral feedings on the algorithm, there was no incidence of NEC in the study group compared with 11% in the control group. CONCLUSION The use of an enteral feeding algorithm is a safe and effective means of initiating and advancing enteral nutrition in infants with HLHS following stage I palliation.
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Rossi AF, Fishberger S, Hannan RL, Nieves JA, Bolivar J, Dobrolet N, Burke RP. Frequency and indications for tracheostomy and gastrostomy after congenital heart surgery. Pediatr Cardiol 2009; 30:225-31. [PMID: 19011726 DOI: 10.1007/s00246-008-9324-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Revised: 09/15/2008] [Accepted: 10/16/2008] [Indexed: 11/29/2022]
Abstract
Patients undergoing congenital heart surgery may occasionally require additional surgical procedures in the form of tracheostomy and gastrostomy. These procedures are often performed in an attempt to diminish hospital morbidity and length of stay. We reviewed the Web-based medical records of all patients undergoing congenital heart surgery at Miami Children's Hospital from February 2002 through August 2007. Patients who were deemed preterm and had undergone closure of a patent ductus arteriosis were eliminated. The records of all other patients were queried for the terms gastrostomy, g-tube, Nissan, fundal plication, tracheostomy, or tracheotomy. Patients' medical records in which these terms appeared in any portion were completely reviewed. There were 1660 congenital heart operations performed in the study period. There were 592 operations performed on patients whose age ranged from 1 month to 1 year and 441 neonatal operations. Mortality was 2%. Median postoperative stay was 8 days (range, 1-191 days), 12 days for neonates (range, 3-142 days), and 19 days for neonates undergoing RACHS-1 category 6 operations (range, 4-142 days). Tracheostomies were performed in four patients (0.2%). Gastrostomies were performed on eight patients (0.4%), representing 0.8% of patients <1 year of age, 1.4% of neonates, and 2.4% of patients undergoing RACHS-1 category 6 operations. The rate of patients undergoing either tracheostomy or gastrostomy after congenital heart surgery at our institution was quite low. Avoidance of either of these two procedures was achieved without increased morbidity or length of stay. The rate at which these procedures need to be performed may reflect the magnitude of the patients' lifetime trauma related to their underlying condition and acute and total surgical experiences.
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Affiliation(s)
- Anthony F Rossi
- Congenital Heart Institute, Miami Children's Hospital, Miami, FL 33155, USA.
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Lai L, Laussen PC, Cua CL, Wessel DL, Costello JM, del Nido PJ, Mayer JE, Thiagarajan RR. Outcomes after bidirectional Glenn operation: Blalock-Taussig shunt versus right ventricle-to-pulmonary artery conduit. Ann Thorac Surg 2007; 83:1768-73. [PMID: 17462397 DOI: 10.1016/j.athoracsur.2006.11.076] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2006] [Revised: 11/21/2006] [Accepted: 11/22/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND There are distinct physiologic differences between patients with single-ventricle lesions who have undergone the Norwood procedure with a right ventricle-to-pulmonary artery conduit (NW-RVPA) compared with those patients who have undergone the Norwood operation with a Blalock-Taussig shunt (NW-BTS). We evaluated bidirectional Glenn operation outcomes and compared the two groups to assess whether the type of Norwood operation influenced outcomes. METHODS A retrospective chart review compared bidirectional Glenn operation outcomes for children undergoing the Norwood operation with NW-RVPA or NW-BTS at Children's Hospital Boston from January 1, 2002, to December 31, 2003. RESULTS Of 80 patients undergoing the Norwood operation, 56 (NW-BTS, 27 versus NW-RVPA, 29) returned for the bidirectional Glenn operation at our institution. The NW-RVPA group had a lower median age at presentation for bidirectional Glenn (4.5 months versus 5.8 months; p = 0.01), but had better weight gain (20.6 g/day versus 16.5 g/day; p = 0.03) than the NW-BTS group. No interstage deaths occurred in the NW-RVPA group. There were no differences in morbidity or mortality after the BDG between the two groups. CONCLUSIONS There were no differences in morbidity and mortality outcomes after the bidirectional Glenn operation between the NW-RVPA and NW-BTS groups. Despite younger age at presentation, the NW-RVPA patients had better growth rate, which may have contributed to the similar postoperative outcomes.
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Affiliation(s)
- Lillian Lai
- Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts, USA.
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Jeffries HE, Wells WJ, Starnes VA, Wetzel RC, Moromisato DY. Gastrointestinal morbidity after Norwood palliation for hypoplastic left heart syndrome. Ann Thorac Surg 2006; 81:982-7. [PMID: 16488706 DOI: 10.1016/j.athoracsur.2005.09.001] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Revised: 08/29/2005] [Accepted: 09/01/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Neonates with hypoplastic left heart syndrome are at high risk for developing gastrointestinal complications after first stage palliation. These complications likely play a major role in their morbidity and mortality. The goal of this review was to examine the incidence and clinical impact of gastrointestinal morbidities in these newborns. METHODS The charts of all neonates with hypoplastic left heart syndrome who underwent stage-one palliation between January 1997 and December 2001 were reviewed to determine the incidence of gastrointestinal complications. Demographic, perioperative, and procedural variables were collected and correlated with major gastrointestinal problems. RESULTS There were 117 patients in our study population, and survival to discharge was 87% (102 of 117). Gastrointestinal complications occurred in 48 (41%), including 18% with necrotizing enterocolitis, 18% who required home feeding tubes, and 8% who required prolonged hospital length of stay for nutritional support. These infants had a longer length of stay (52 days versus 22 days; p < 0.0001). Multivariate logistic regression analysis revealed that weight less than 2.5 kg and development of necrotizing enterocolitis were each independently related to death. Neonates with a birth weight less than 2.5 kg had an odds ratio for death of 5.7 (95% confidence interval: 1.14 to 28.86), and the odds ratio for death with necrotizing enterocolitis was 5.6 (95% confidence interval: 1.55 to 20.67). CONCLUSIONS Gastrointestinal complications in infants with hypoplastic left heart syndrome are common, and necrotizing enterocolitis increases the risk of death. Measures directed at reducing the incidence of gastrointestinal complications may improve outcomes and reduce costs in this population.
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Affiliation(s)
- Howard E Jeffries
- Department of Anesthesiology, Critical Care Medicine, Childrens Hospital Los Angeles, Los Angeles, California, USA.
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