1
|
Kimura S, Shimizu K, Izumi K, Kanazawa T, Mizuno K, Iwasaki T, Morimatsu H. Regional Cerebral Oxygen Saturation and Estimated Oxygen Extraction Ratio as Predictive Markers of Major Adverse Events in Infants with Congenital Heart Disease. Pediatr Cardiol 2024; 45:1398-1406. [PMID: 37029812 DOI: 10.1007/s00246-023-03158-1] [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: 01/12/2023] [Accepted: 03/28/2023] [Indexed: 04/09/2023]
Abstract
Regional cerebral oxygen saturation (ScO2) determined by near-infrared spectroscopy, monitoring both arterial and venous blood oxygenation of the brain, could reflect the balance between oxygen delivery and consumption. The aim of this study was to determine the predictabilities of ScO2 and estimated oxygen extraction ratio (eO2ER) with outcomes in infants with congenital heart disease (CHD). This study was a two-center, retrospective study of patients at 12 months of age or younger with CHD who underwent cardiac surgery. The primary outcome was a composite of one or more major adverse events (MAEs) after surgery: death from any cause, circulatory collapse that needed cardiopulmonary resuscitation, and requirement for extracorporeal membrane oxygenation. Based on the assumptions of arterial to venous blood ratio, eO2ER was calculated. A total of 647 cases were included in this study. MAEs occurred in 16 patients (2.5%). There were significant differences in post-bypass ScO2 [46.61 (40.90, 52.05) vs. 58.52 (51.52, 66.08), p < 0.001] and post-bypass eO2ER [0.66 (0.60, 0.78) vs. 0.52 (0.43, 0.61), p < 0.001] between patients with MAEs and patients without MAEs. Area under the receiver operating curve (AUROC) of post-bypass ScO2 was 0.818 (95% confidence interval: 0.747-0.889), AUROC of post-bypass eO2ER was 0.783 (0.697-0.870) and AUROC of post-bypass maximum serum lactate level was 0.635 (0.525-0.746). Both ScO2 and eO2ER, especially after weaning off bypass, are acceptable predictive markers for predicting MAEs after cardiac surgery in infants.(227 words).
Collapse
Affiliation(s)
- Satoshi Kimura
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan.
| | - Kazuyoshi Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Kaoru Izumi
- Department of Anesthesia, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Higashi-Ku, Fukuoka, 813-0017, Japan
| | - Tomoyuki Kanazawa
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Keiichiro Mizuno
- Department of Anesthesia, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Higashi-Ku, Fukuoka, 813-0017, Japan
| | - Tatsuo Iwasaki
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| |
Collapse
|
2
|
Pardo AC, Carrasco M, Wintermark P, Nunes D, Chock VY, Sen S, Wusthoff CJ. Neuromonitoring practices for neonates with congenital heart disease: a scoping review. Pediatr Res 2024:10.1038/s41390-024-03484-x. [PMID: 39183308 DOI: 10.1038/s41390-024-03484-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/30/2024] [Accepted: 08/01/2024] [Indexed: 08/27/2024]
Abstract
Neonates with congenital heart disease (CHD) are at risk for adverse neurodevelopmental outcomes. This scoping review summarizes neuromonitoring methods in neonates with CHD. We identified 84 studies investigating the use of near-infrared spectroscopy (NIRS) (n = 37), electroencephalography (EEG) (n = 20), amplitude-integrated electroencephalography (aEEG) (n = 10), transcranial Doppler sonography (TCD) (n = 6), and multimodal monitoring (n = 11). NIRS was used to evaluate cerebral oxygenation, identify risk thresholds and adverse events in the intensive care unit (ICU), and outcomes. EEG was utilized to screen for seizures and to predict adverse outcomes. Studies of aEEG have focused on characterizing background patterns, detecting seizures, and outcomes. Studies of TCD have focused on correlation with short-term clinical outcomes. Multimodal monitoring studies characterized cerebral physiologic dynamics. Most of the studies were performed in single centers, had a limited number of neonates (range 3-183), demonstrated variability in neuromonitoring practices, and lacked standardized approaches to neurodevelopmental testing. We identified areas of improvement for future research: (1) large multicenter studies to evaluate developmental correlates of neuromonitoring practices; (2) guidelines to standardize neurodevelopmental testing methodologies; (3) research to address geographic variation in resource utilization; (4) integration and synchronization of multimodal monitoring; and (5) research to establish a standardized framework for neuromonitoring techniques across diverse settings. IMPACT: This scoping review summarizes the literature regarding neuromonitoring practices in neonates with congenital heart disease (CHD). The identification of low cerebral oxygenation thresholds with NIRS may be used to identify neonates at risk for adverse events in the ICU or adverse neurodevelopmental outcomes. Postoperative neuromonitoring with continuous EEG screening for subclinical seizures and status epilepticus, allow for early and appropriate therapy. Future studies should focus on enrolling larger multicenter cohorts of neonates with CHD with a standardized framework of neuromonitoring practices in this population. Postoperative neurodevelopmental testing should utilize standard assessments and testing intervals.
Collapse
Affiliation(s)
- Andrea C Pardo
- Department of Pediatrics (Neurology and Epilepsy). Northwestern University Feinberg School of Medicine, Chicago, IL, US.
| | - Melisa Carrasco
- Department of Neurology. University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Pia Wintermark
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, Montreal, Qc, Canada
| | - Denise Nunes
- Galter Health Sciences Library. Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Valerie Y Chock
- Department of Pediatrics (Neonatology), Lucile Packard Children's Hospital and Stanford University, Palo Alto, CA, US
| | - Shawn Sen
- Department of Pediatrics (Neonatology). Northwestern University Feinberg School of Medicine, Chicago, IL, US
- Department of Pediatrics, University of California Irvine, Orange, CA, US
| | | |
Collapse
|
3
|
Pezzato S, Govindan RB, Bagnasco F, Panagopoulos EM, Robba C, Beqiri E, Smielewski P, Munoz RA, d'Udekem Y, Moscatelli A, du Plessis A. Cerebral autoregulation monitoring using the cerebral oximetry index after neonatal cardiac surgery: A single-center retrospective cohort study. J Thorac Cardiovasc Surg 2024; 168:353-363.e4. [PMID: 38065519 DOI: 10.1016/j.jtcvs.2023.12.003] [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: 09/01/2023] [Revised: 10/31/2023] [Accepted: 12/03/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To investigate whether cerebral autoregulation is impaired after neonatal cardiac surgery and whether changes in autoregulation metrics are associated with different congenital heart defects or the incidence of postoperative neurologic events. METHODS This is a retrospective observational study of neonates undergoing monitoring during the first 72 hours after cardiac surgery. Archived data were processed to calculate the cerebral oximetry index (COx) and derived metrics. Acute neurologic events were identified by an electronic medical record review. The Skillings-Mack test and the Wilcoxon signed-rank test were used to analyze the evolution of autoregulation metrics over time; the Mann-Whitney U test was used for comparison between groups. RESULTS We included 28 neonates, 7 (25%) with hypoplastic left heart syndrome and 21 (75%) with transposition of the great arteries. Overall, the median percentage of time spent with impaired autoregulation, defined as percentage of time with a COx >0.3, was 31.6% (interquartile range, 21.1%-38.3%). No differences in autoregulation metrics between different cardiac defects subgroups were observed. Seven patients (25%) experienced a postoperative acute neurologic event. Compared to the neonates without an acute neurologic event, those with an acute neurologic event had a higher COx (0.16 vs 0.07; P = .035), a higher percentage of time with a COx >0.3 (39.4% vs 29.2%; P = .017), and a higher percentage of time with a mean arterial pressure below the lower limit of autoregulation (13.3% vs 6.9%; P = .048). CONCLUSIONS COx monitoring after cardiac surgery allowed for the detection of impaired cerebral autoregulation, which was more frequent in neonates with postoperative acute neurologic events.
Collapse
Affiliation(s)
- Stefano Pezzato
- Neonatal and Pediatric Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy; Division of Cardiovascular Surgery, Children's National Hospital, Washington, DC.
| | | | - Francesca Bagnasco
- Epidemiology and Biostatistics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Chiara Robba
- Anesthesia and Critical Care, IRCCS Policlinico San Martino, Genova, Italy
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ricardo A Munoz
- Division of Cardiac Critical Care Medicine, Children's National Hospital, Washington, DC
| | - Yves d'Udekem
- Division of Cardiovascular Surgery, Children's National Hospital, Washington, DC
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Adre du Plessis
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC
| |
Collapse
|
4
|
Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024; 44:362-388. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
Collapse
Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| |
Collapse
|
5
|
Still B. Near-infrared spectroscopy: indications and interpretation. Int Anesthesiol Clin 2024; 62:48-52. [PMID: 38112200 DOI: 10.1097/aia.0000000000000430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Affiliation(s)
- Brady Still
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| |
Collapse
|
6
|
Massey SL, Weinerman B, Naim MY. Perioperative Neuromonitoring in Children with Congenital Heart Disease. Neurocrit Care 2024; 40:116-129. [PMID: 37188884 DOI: 10.1007/s12028-023-01737-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
Although neonates and children with congenital heart disease are primarily hospitalized for cardiac and pulmonary diseases, they are also at an increased risk for neurologic injury due to both empiric differences that can exist in their nervous systems and acquired injury from cardiopulmonary pathology and interventions. Although early efforts in care focused on survival after reparative cardiac surgery, as surgical and anesthetic techniques have evolved and survival rates accordingly improved, the focus has now shifted to maximizing outcomes among survivors. Children and neonates with congenital heart disease experience seizures and poor neurodevelopmental outcomes at a higher rate than age-matched counterparts. The aim of neuromonitoring is to help clinicians identify patients at highest risk for these outcomes to implement strategies to mitigate these risks and to also help with neuroprognostication after an injury has occurred. The mainstays of neuromonitoring are (1) electroencephalographic monitoring to evaluate brain activity for abnormal patterns or changes and to identify seizures, (2) neuroimaging to reveal structural changes and evidence of physical injury in and around the brain, and (3) near-infrared spectroscopy to monitor brain tissue oxygenation and detect changes in perfusion. This review will detail the aforementioned techniques and their use in the care of pediatric patients with congenital heart disease.
Collapse
Affiliation(s)
- Shavonne L Massey
- Division of Neurology, Department of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | - Bennett Weinerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Maryam Y Naim
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology, Critical Care Medicine, and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
7
|
Phillips K, Callaghan B, Rajagopalan V, Akram F, Newburger JW, Kasparian NA. Neuroimaging and Neurodevelopmental Outcomes Among Individuals With Complex Congenital Heart Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:2225-2245. [PMID: 38030353 DOI: 10.1016/j.jacc.2023.09.824] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/13/2023] [Indexed: 12/01/2023]
Abstract
Although neuroimaging advances have deepened our understanding of brain health in individuals with congenital heart disease (CHD), it is less clear how neuroimaging findings relate to neurodevelopmental and mental health outcomes across the lifespan. We systematically synthesized and critically evaluated evidence on associations between neuroimaging and neurodevelopmental, neurocognitive, psychiatric, or behavioral outcomes among individuals with transposition of great arteries or single-ventricle CHD (Protocol CRD42021229617). Six databases were searched and 45 papers from 25 unique studies were identified. Structural brain injury was generally linked to poorer neurodevelopment in infancy. Brain volumes and microstructural and functional brain changes appear linked to neurocognitive outcomes, including deficits in attention, learning, memory, and executive function in children and adolescents. Fetal neuroimaging studies were limited. Four papers investigated psychiatric outcomes; none found associations with neuroimaging. Multicenter, longitudinal studies incorporating functional neuroimaging and mental health outcomes are much-needed to inform early neuroprotective and therapeutic strategies in CHD.
Collapse
Affiliation(s)
- Katelyn Phillips
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bridget Callaghan
- Department of Psychology, University of California Los Angeles, Los Angeles, California, USA
| | - Vidya Rajagopalan
- Department of Radiology, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Farah Akram
- Discipline of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Nadine A Kasparian
- Heart and Mind Wellbeing Center, Heart Institute and the Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| |
Collapse
|
8
|
Pieciak K, McGowan K, Grade L, Morrill D, DiPasquale Z, Casto E, Connor JA, Lisanti AJ. Nurses' perceptions and use of near infrared spectroscopy in paediatric cardiac intensive care. Nurs Crit Care 2023; 28:1045-1052. [PMID: 36418164 DOI: 10.1111/nicc.12861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 10/29/2022] [Accepted: 11/03/2022] [Indexed: 10/31/2023]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) is a non-invasive technology that estimates regional oxygen saturation. Literature demonstrates that NIRS can provide valuable data for clinical staff. However, little research has addressed the nursing care and management of NIRS in the critical care environment. AIMS To assess nurses' perception around the use of NIRS and current NIRS practice within paediatric cardiac intensive care unit (PCICUs). STUDY DESIGN A 53-item cross-sectional electronic survey was developed to assess indications for NIRS, critical value thresholds and interventions, barriers to use, policies and procedures, and nursing perceptions. Descriptive statistics were used to summarize and aggregate data. RESULTS Among the 28 responding sites (63.6% response rate), usage of NIRS was variable and patient-dependent. Most nurses reported using NIRS in patients with unstable physiology such as post-operative single ventricle (n = 25, 89.3%) and concern for shock (n = 21, 75.0%). Critically low cerebral values varied among respondents from less than 40 (n = 3, 10.7%) to less than 60 (n = 4, 14.3%), with lower critical values permitted for single ventricle physiology: less than 40 (n = 8, 28.6%) to less than 50 (n = 6, 21.4%). Reported barriers to using NIRS included skin breakdown (n = 9, 32.1%), lack of consistency in decision-making among physicians (n = 13, 46.4%), and not using NIRS data when developing a plan of care (n = 11, 39.3%). Most (n = 24, 85.7%) nurses reported that NIRS provided valuable information and was perceived to be beneficial for patients. CONCLUSIONS NIRS monitoring is a common technology in the care of complex congenital heart disease patients. Most nurses valued this technology, but inconsistencies and practicalities around its use in guiding patient management were found to be problematic. RELEVANCE TO CLINICAL PRACTICE NIRS is commonly used in the PCICU and although nurses perceived NIRS to be useful for their practice, the variability in the interpretation of values and inconsistent protocols and decision-making by physicians was challenging.
Collapse
Affiliation(s)
- Karyn Pieciak
- Department of Nursing and Clinical Care Services, Cardiac Intensive Care Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kendal McGowan
- Department of Nursing and Clinical Care Services, Cardiac Intensive Care Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lori Grade
- Department of Nursing, Cardiac Center, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Diana Morrill
- Cardiovascular, Critical Care and Perioperative, Patient Services, Project Coordinator II, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Zachary DiPasquale
- Cardiovascular, Critical Care and Perioperative, Patient Services, Program Administrative Manager III, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Elizabeth Casto
- Department of Cardiology, Quality Improvement Consultant, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jean A Connor
- Cardiovascular, Critical Care and Perioperative, Patient Services, Director of Nursing Research, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Amy J Lisanti
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
9
|
Surma VJ, Patel A, Ng DK, Goswami DK, Garcia AV, Bembea MM. Effect of Red Blood Cell Transfusion on Regional Tissue Oxygenation in Pediatric Cardiac Surgery Patients. Anesth Analg 2023; 137:987-995. [PMID: 37036824 PMCID: PMC10562511 DOI: 10.1213/ane.0000000000006479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
BACKGROUND Red blood cell (RBC) transfusions are used frequently in pediatric patients admitted to the intensive care unit (ICU) after cardiac surgery. To improve data-driven transfusion decision-making in the ICU, we conducted a retrospective analysis to assess the effect of RBC transfusion on cerebral and somatic regional oxygenation (rSO2). METHODS We evaluated post- versus pre-RBC transfusion cerebral rSO2 and somatic rSO2 in all consecutive pediatric patients (age >28 days to <18 years) who underwent biventricular cardiac surgery at a single center between July 2016 and April 2020. RESULTS The final data set included 263 RBC postoperative transfusion events in 75 patients who underwent 83 surgeries. The median pretransfusion hemoglobin was 10.6 g/dL (25th-75th percentile, 9.3-11.6). The median pretransfusion cerebral and somatic rSO2 were 63% (54-71) and 69% (55-80), which increased by a median of 3 percentage points (-2 to 6) and 2 percentage points (-3 to 6), respectively, after transfusion. After adjusting for pretransfusion hemoglobin, change in hemoglobin posttransfusion versus pretransfusion, and potential confounders (age, sex, and STAT surgical mortality risk score), the posttransfusion versus pretransfusion change in cerebral or somatic rSO2 was not statistically significant. Pretransfusion cerebral rSO2 (crSO2) was ≤50%, a previously described threshold for increased risk for unfavorable neurological outcome, for 22 of 138 (16%) transfusion events with complete pre- and post-crSO2 data. Sixteen of these 22 (73%) transfusions resulted in a posttransfusion crSO2 >50%. When restricting analysis to the first (index) transfusion after arrival to the ICU from the operating room (administered at a median of 1.15 postoperative days [25th-75th percentile, 0.84-1.93]), between-patient pretransfusion hemoglobin was not associated with pretransfusion crSO2 but within-patient posttransfusion versus pretransfusion hemoglobin difference was significantly associated with posttransfusion versus pretransfusion crSO2 difference (mean posttransfusion versus pretransfusion crSO2 difference, 2.54; 95% confidence interval, 0.50-4.48). CONCLUSIONS In this study, neither cerebral nor somatic rSO2 increased significantly post- versus pre-RBC transfusion in pediatric cardiac surgery patients admitted to the ICU after biventricular repairs. However, almost three-quarters of transfusions administered when pretransfusion crSO2 was below the critical threshold of 50% resulted in a posttransfusion crSO2 >50%. In addition, the significant within-patient change in crSO2 in relation to the change in posttransfusion versus pretransfusion hemoglobin in the immediate postoperative period suggests that a personalized approach to transfusion following within-patient trends of crSO2 rather than absolute between-patient values may be an important focus for future research.
Collapse
Affiliation(s)
- Victoria J Surma
- From the Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ankur Patel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Dheeraj K Goswami
- From the Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alejandro V Garcia
- Department of Surgery (Pediatric), Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melania M Bembea
- From the Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
10
|
Abubakar MO, Zanelli SA, Spaeder MC. Changes in Cerebral Regional Oxygen Saturation Variability in Neonates Undergoing Cardiac Surgery: A Prospective Cohort Study. Pediatr Cardiol 2023; 44:1560-1565. [PMID: 37468575 DOI: 10.1007/s00246-023-03239-1] [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: 02/27/2023] [Accepted: 07/09/2023] [Indexed: 07/21/2023]
Abstract
Near-infrared spectroscopy is routinely used in the monitoring of cerebral regional oxygen saturation (crSO2) in neonates following congenital heart surgery. Decreased postoperative crSO2 variability in these patients is associated with worse clinical outcomes, including neurodevelopmental outcomes. We sought to explore changes in crSO2 variability between the preoperative and postoperative periods and associations with short-term clinical outcomes in neonates undergoing cardiac surgery. We performed a prospective cohort study of neonates undergoing cardiac surgery with cardiopulmonary bypass between November 2019 and May 2021. We calculated crSO2 variability using averaged 1 min of crSO2 values for a minimum of 12 h before, and the first 48 h following surgery. 37 neonates (median age at start of monitoring 4 days (interquartile range 2-5 days)) were included in our study. We observed a 30% decrease in crSO2 variability between the preoperative and postoperative monitoring periods (p < 0.001). Preoperative crSO2 variability increased by 9% (p = 0.009) for each additional postnatal day. There were no associations between the degree of decrease in crSO2 variability postoperatively and class of cardiac lesion (e.g., aortic arch obstruction, single ventricle physiology) or short-term postoperative clinical outcomes. There was a significant decrease in postoperative crSO2 variability following neonatal cardiac surgery as compared to the preoperative period, likely influenced by several factors. The impact of interventions on crSO2 variability and resultant influence on long-term outcomes, such as neurodevelopmental outcomes, requires further exploration.
Collapse
Affiliation(s)
- Maryam O Abubakar
- Division of Neonatal-Perinatal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Santina A Zanelli
- Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Michael C Spaeder
- Division of Pediatric Critical Care, University of Virginia School of Medicine, PO Box 800386, Charlottesville, VA, 22908, USA.
| |
Collapse
|
11
|
Yu P, Skinner M, Esangbedo I, Lasa JJ, Li X, Natarajan S, Raman L. Predicting Cardiac Arrest in Children with Heart Disease: A Novel Machine Learning Algorithm. J Clin Med 2023; 12:jcm12072728. [PMID: 37048811 PMCID: PMC10095110 DOI: 10.3390/jcm12072728] [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: 02/06/2023] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Children with congenital and acquired heart disease are at a higher risk of cardiac arrest compared to those without heart disease. Although the monitoring of cardiopulmonary resuscitation quality and extracorporeal resuscitation technologies have advanced, survival after cardiac arrest in this population has not improved. Cardiac arrest prevention, using predictive algorithms with machine learning, has the potential to reduce cardiac arrest rates. However, few studies have evaluated the use of these algorithms in predicting cardiac arrest in children with heart disease. METHODS We collected demographic, laboratory, and vital sign information from the electronic health records (EHR) of all the patients that were admitted to a single-center pediatric cardiac intensive care unit (CICU), between 2010 and 2019, who had a cardiac arrest during their CICU admission, as well as a comparator group of randomly selected non-cardiac-arrest controls. We compared traditional logistic regression modeling against a novel adaptation of a machine learning algorithm (functional gradient boosting), using time series data to predict the risk of cardiac arrest. RESULTS A total of 160 unique cardiac arrest events were matched to non-cardiac-arrest time periods. Using 11 different variables (vital signs and laboratory values) from the EHR, our algorithm's peak performance for the prediction of cardiac arrest was at one hour prior to the cardiac arrest (AUROC of 0.85 [0.79,0.90]), a performance that was similar to our previously published multivariable logistic regression model. CONCLUSIONS Our novel machine learning predictive algorithm, which was developed using retrospective data that were collected from the EHR and predicted cardiac arrest in the children that were admitted to a single-center pediatric cardiac intensive care unit, demonstrated a performance that was similar to that of a traditional logistic regression model. While these results are encouraging, future research, including prospective validations with multicenter data, is warranted prior to the implementation of this algorithm as a real-time clinical decision support tool.
Collapse
Affiliation(s)
- Priscilla Yu
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Michael Skinner
- Department of Computer Science, University of Texas at Dallas, Richardson, TX 75080, USA
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Ivie Esangbedo
- Section of Cardiac Critical Care, Division of Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
| | - Javier J Lasa
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Xilong Li
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| | - Sriraam Natarajan
- Department of Computer Science, University of Texas at Dallas, Richardson, TX 75080, USA
| | - Lakshmi Raman
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75235, USA
| |
Collapse
|
12
|
Sullivan BA, Kausch SL, Fairchild KD. Artificial and human intelligence for early identification of neonatal sepsis. Pediatr Res 2023; 93:350-356. [PMID: 36127407 DOI: 10.1038/s41390-022-02274-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022]
Abstract
Artificial intelligence may have a role in the early detection of sepsis in neonates. Machine learning can identify patterns that predict high or increasing risk for clinical deterioration from a sepsis-like illness. In developing this potential addition to NICU care, careful consideration should be given to the data and methods used to develop, validate, and evaluate prediction models. When an AI system alerts clinicians to a change in a patient's condition that warrants a bedside evaluation, human intelligence and experience come into play to determine an appropriate course of action: evaluate and treat or wait and watch closely. With intelligently developed, validated, and implemented AI sepsis systems, both clinicians and patients stand to benefit. IMPACT: This narrative review highlights the application of AI in neonatal sepsis prediction. It describes issues in clinical prediction model development specific to this population. This article reviews the methods, considerations, and literature on neonatal sepsis model development and validation. Challenges of AI technology and potential barriers to using sepsis AI systems in the NICU are discussed.
Collapse
Affiliation(s)
- Brynne A Sullivan
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Sherry L Kausch
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Karen D Fairchild
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| |
Collapse
|
13
|
Spaeder MC, Keller JM, Sawda CN, Surma VJ, Platter EN, White DN, Smith CJ, Harmon WG. Implementation of a Regional Oxygen Saturation Thought Algorithm and Association with Clinical Outcomes in Pediatric Patients Following Cardiac Surgery. Pediatr Cardiol 2022; 44:940-945. [PMID: 36512036 PMCID: PMC9745270 DOI: 10.1007/s00246-022-03071-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
Near infrared spectroscopy is routinely used in the noninvasive monitoring of cerebral and somatic regional oxygen saturation (rSO2) in pediatric patients following surgery for congenital heart disease. We sought to evaluate the association of a bedside rSO2 thought algorithm with clinical outcomes in a cohort of pediatric patients following cardiac surgery. This was a single-center retrospective cohort study of patients admitted following cardiac surgery over a 42-month period. The intervention was the implementation of an rSO2 thought algorithm, the primary goal of which was to supply bedside providers with a thought aide to help identify, and guide response to, changes in rSO2 in post-operative cardiac surgical patients. Surgical cases were stratified into two 18-month periods of observation, pre- and post-intervention allowing for a 6-month washout period during implementation of the thought algorithm. Clinical outcomes were compared between pre- and post-intervention periods. There were 434 surgical cases during the period of study. We observed a 27% relative risk reduction in our standardized mortality rate (0.61 to 0.48, p = 0.01) between the pre- and post-intervention periods. We did not observe differences in other post-operative clinical outcomes such as ventilator free days or post-operative ICU length of stay. Providing frontline clinical staff with education and tools, such as a bedside rSO2 thought algorithm, may aide in the earlier detection of imbalance between oxygen delivery and consumption and may contribute to improved patient outcomes.
Collapse
Affiliation(s)
- Michael C. Spaeder
- Division of Pediatric Critical Care, University of Virginia School of Medicine, Box 800386, Charlottesville, VA 22908 USA ,Center for Advanced Medical Analytics, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Jacqueline M. Keller
- Pediatric Intensive Care Unit, University of Virginia Children’s Hospital, Charlottesville, VA USA
| | - Christine N. Sawda
- Division of Cardiology, Children’s National Hospital, Washington, DC USA
| | - Victoria J. Surma
- Division of Cardiology, Children’s National Hospital, Washington, DC USA
| | - Erin N. Platter
- Division of Pediatric Critical Care, University of Virginia School of Medicine, Box 800386, Charlottesville, VA 22908 USA
| | - Douglas N. White
- Pediatric Intensive Care Unit, University of Virginia Children’s Hospital, Charlottesville, VA USA
| | - Clyde J. Smith
- Division of Pediatric Critical Care, University of Virginia School of Medicine, Box 800386, Charlottesville, VA 22908 USA ,Division of Pediatric Cardiology, University of Virginia School of Medicine, Charlottesville, VA USA
| | - William G. Harmon
- Division of Pediatric Critical Care, University of Virginia School of Medicine, Box 800386, Charlottesville, VA 22908 USA
| |
Collapse
|
14
|
Early Cerebrovascular Autoregulation in Neonates with Congenital Heart Disease. CHILDREN 2022; 9:children9111686. [DOI: 10.3390/children9111686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/28/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
Neonates with congenital heart disease (CHD) display delayed brain development, predisposing them to impaired cerebrovascular autoregulation (CAR) and ischemic brain injury. For this paper, we analyzed the percentage of time with impaired CAR (%time impaired CAR) during the first 72 h after birth, the relation with clinical factors, and survival in 57 neonates with CHD. The primary outcome was a correlation coefficient of cerebral oxygenation (rcSO2) and mean arterial blood pressure (MABP, mmHg) for two hours on a daily basis. The %time impaired CAR ranged from 9.3% of the studied time on day one to 4.6% on day three. Variables associated with more %time impaired CAR were the use of inotropes (day 1, B = 19.5, 95%CI = 10.6–28.3; day 3, B = 11.5, 95%CI = 7.1–16), lower MABP (day 1, B = −0.6, 95%CI = −1.2–0.0), and dextro-transposition of the great arteries (dTGA) (16.2%) compared with other CHD types (2.0–5.0%; day 1, p = 0.022). Survival was not an associated variable. To summarize, impaired CAR was found in CHD neonates in up to 9.3% of the studied time. More evidence is necessary to evaluate an association with inotropes, dTGA, %time impaired CAR, and long-term outcome, further in larger cohorts.
Collapse
|
15
|
Ortinau CM, Smyser CD, Arthur L, Gordon EE, Heydarian HC, Wolovits J, Nedrelow J, Marino BS, Levy VY. Optimizing Neurodevelopmental Outcomes in Neonates With Congenital Heart Disease. Pediatrics 2022; 150:e2022056415L. [PMID: 36317967 PMCID: PMC10435013 DOI: 10.1542/peds.2022-056415l] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Abstract
Neurodevelopmental impairment is a common and important long-term morbidity among infants with congenital heart disease (CHD). More than half of those with complex CHD will demonstrate some form of neurodevelopmental, neurocognitive, and/or psychosocial dysfunction requiring specialized care and impacting long-term quality of life. Preventing brain injury and treating long-term neurologic sequelae in this high-risk clinical population is imperative for improving neurodevelopmental and psychosocial outcomes. Thus, cardiac neurodevelopmental care is now at the forefront of clinical and research efforts. Initial research primarily focused on neurocritical care and operative strategies to mitigate brain injury. As the field has evolved, investigations have shifted to understanding the prenatal, genetic, and environmental contributions to impaired neurodevelopment. This article summarizes the recent literature detailing the brain abnormalities affecting neurodevelopment in children with CHD, the impact of genetics on neurodevelopmental outcomes, and the best practices for neonatal neurocritical care, focusing on developmental care and parental support as new areas of importance. A framework is also provided for the infrastructure and resources needed to support CHD families across the continuum of care settings.
Collapse
Affiliation(s)
- Cynthia M. Ortinau
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Christopher D. Smyser
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
| | - Lindsay Arthur
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Erin E. Gordon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Haleh C. Heydarian
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Joshua Wolovits
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan Nedrelow
- Department of Neonatology, Cook Children’s Medical Center, Fort Worth, Texas
| | - Bradley S. Marino
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Divisions of Cardiology and Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Victor Y. Levy
- Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children’s Hospital, Palo Alto, California
| |
Collapse
|
16
|
Schmithorst VJ, Adams PS, Badaly D, Lee VK, Wallace J, Beluk N, Votava-Smith JK, Weinberg JG, Beers SR, Detterich J, Wood JC, Lo CW, Panigrahy A. Impaired Neurovascular Function Underlies Poor Neurocognitive Outcomes and Is Associated with Nitric Oxide Bioavailability in Congenital Heart Disease. Metabolites 2022; 12:metabo12090882. [PMID: 36144286 PMCID: PMC9504090 DOI: 10.3390/metabo12090882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 12/03/2022] Open
Abstract
We use a non-invasive MRI proxy of neurovascular function (pnvf) to assess the ability of the vasculature to supply baseline metabolic demand, to compare pediatric and young adult congenital heart disease (CHD) patients to normal referents and relate the proxy to neurocognitive outcomes and nitric oxide bioavailability. In a prospective single-center study, resting-state blood-oxygen-level-dependent (BOLD) and arterial spin labeling (ASL) MRI scans were successfully obtained from 24 CHD patients (age = 15.4 ± 4.06 years) and 63 normal referents (age = 14.1 ± 3.49) years. Pnvf was computed on a voxelwise basis as the negative of the ratio of functional connectivity strength (FCS) estimated from the resting-state BOLD acquisition to regional cerebral blood flow (rCBF) as estimated from the ASL acquisition. Pnvf was used to predict end-tidal CO2 (PETCO2) levels and compared to those estimated from the BOLD data. Nitric oxide availability was obtained via nasal measurements (nNO). Pnvf was compared on a voxelwise basis between CHD patients and normal referents and correlated with nitric oxide availability and neurocognitive outcomes as assessed via the NIH Toolbox. Pnvf was shown as highly predictive of PETCO2 using theoretical modeling. Pnvf was found to be significantly reduced in CHD patients in default mode network (DMN, comprising the ventromedial prefrontal cortex and posterior cingulate/precuneus), salience network (SN, comprising the insula and dorsal anterior cingulate), and central executive network (CEN, comprising posterior parietal and dorsolateral prefrontal cortex) regions with similar findings noted in single cardiac ventricle patients. Positive correlations of Pnvf in these brain regions, as well as the hippocampus, were found with neurocognitive outcomes. Similarly, positive correlations between Pnvf and nitric oxide availability were found in frontal DMN and CEN regions, with particularly strong correlations in subcortical regions (putamen). Reduced Pnvf in CHD patients was found to be mediated by nNO. Mediation analyses further supported that reduced Pnvf in these regions underlies worse neurocognitive outcome in CHD patients and is associated with nitric oxide bioavailability. Impaired neuro-vascular function, which may be non-invasively estimated via combined arterial-spin label and BOLD MR imaging, is a nitric oxide bioavailability dependent factor implicated in adverse neurocognitive outcomes in pediatric and young adult CHD.
Collapse
Affiliation(s)
| | - Phillip S. Adams
- Department of Pediatric Anesthesiology, UPMC Children’s Hospital, Pittsburgh, PA 15224, USA
| | - Daryaneh Badaly
- Learning and Development Center, Child Mind Institute, New York, NY 10022, USA
| | - Vincent K. Lee
- Department of Pediatric Radiology, UPMC Children’s Hospital, Pittsburgh, PA 15224, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Julia Wallace
- Department of Pediatric Radiology, UPMC Children’s Hospital, Pittsburgh, PA 15224, USA
| | - Nancy Beluk
- Department of Pediatric Radiology, UPMC Children’s Hospital, Pittsburgh, PA 15224, USA
| | | | | | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Jon Detterich
- Heart Institute, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - John C. Wood
- Heart Institute, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Cecilia W. Lo
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Ashok Panigrahy
- Department of Pediatric Radiology, UPMC Children’s Hospital, Pittsburgh, PA 15224, USA
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- Correspondence: ; Tel.: +1-412-692-5510; Fax: +1-412-692-6929
| |
Collapse
|
17
|
A diffusion MRI study of brain white matter microstructure in adolescents and adults with a Fontan circulation: Investigating associations with resting and peak exercise oxygen saturations and cognition. Neuroimage Clin 2022; 36:103151. [PMID: 35994923 PMCID: PMC9402393 DOI: 10.1016/j.nicl.2022.103151] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Adolescents and adults with a Fontan circulation are at risk of cognitive dysfunction; Attention and processing speed are notable areas of concern. Underlying mechanisms and brain alterations associated with worse long-term cognitive outcomes are not well determined. This study investigated brain white matter microstructure in adolescents and adults with a Fontan circulation and associations with resting and peak exercise oxygen saturations (SaO2), predicted maximal oxygen uptake during exercise (% pred VO2), and attention and processing speed. METHODS Ninety-two participants with a Fontan circulation (aged 13-49 years, ≥5 years post-Fontan completion) had diffusion MRI. Averaged tract-wise diffusion tensor imaging (DTI) metrics were generated for 34 white matter tracts of interest. Resting and peak exercise SaO2 and % pred VO2 were measured during cardiopulmonary exercise testing (CPET; N = 81). Attention and processing speed were assessed using Cogstate (N = 67 and 70, respectively). Linear regression analyses adjusted for age, sex, and intracranial volume were performed to investigate associations between i) tract-specific DTI metrics and CPET variables, and ii) tract-specific DTI metrics and attention and processing speed z-scores. RESULTS Forty-nine participants were male (53%), mean age was 23.1 years (standard deviation (SD) = 7.8 years). Mean resting and peak exercise SaO2 were 93.1% (SD = 3.6) and 90.1% (SD = 4.7), respectively. Mean attention and processing speed z-scores were -0.63 (SD = 1.07) and -0.72 (SD = 1.44), respectively. Resting SaO2 were positively associated with mean fractional anisotropy (FA) of the left corticospinal tract (CST) and right superior longitudinal fasciculus I (SLF-I) and negatively associated with mean diffusivity (MD) and radial diffusivity (RD) of the right SLF-I (p ≤ 0.01). Peak exercise SaO2 were positively associated with mean FA of the left CST and were negatively associated with mean RD of the left CST, MD of the left frontopontine tract, MD, RD and axial diffusivity (AD) of the right SLF-I, RD of the left SLF-II, MD, RD and AD of the right SLF-II, and MD and RD of the right SLF-III (p ≤ 0.01). Percent predicted VO2 was positively associated with FA of the left uncinate fasciculus (p < 0.01). Negative associations were identified between mean FA of the right arcuate fasciculus, right SLF-II and right SLF-III and processing speed (p ≤ 0.01). No significant associations were identified between DTI-based metrics and attention. CONCLUSION Chronic hypoxemia may have long-term detrimental impact on white matter microstructure in people living with a Fontan circulation. Paradoxical associations between processing speed and tract-specific DTI metrics could be suggestive of compensatory white matter remodeling. Longitudinal investigations focused on the mechanisms and trajectory of altered white matter microstructure and associated cognitive dysfunction in people with a Fontan circulation are required to better understand causal associations.
Collapse
|
18
|
Sullivan BA, Fairchild KD. Vital signs as physiomarkers of neonatal sepsis. Pediatr Res 2022; 91:273-282. [PMID: 34493832 DOI: 10.1038/s41390-021-01709-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/24/2021] [Accepted: 07/27/2021] [Indexed: 02/08/2023]
Abstract
Neonatal sepsis accounts for significant morbidity and mortality, particularly among premature infants in the Neonatal Intensive Care Unit. Abnormal vital sign patterns serve as physiomarkers of sepsis and provide early warning of illness before overt clinical decompensation. The systemic inflammatory response to pathogens signals the autonomic nervous system, leading to changes in temperature, respiratory rate, heart rate, and blood pressure. In infants with comorbidities of prematurity, vital sign abnormalities often occur in the absence of infection, which confounds sepsis diagnosis. This review will cover the mechanisms of vital sign changes in neonatal sepsis, including the cholinergic anti-inflammatory pathway mediated by the vagus nerve, which is critical to the host response to infectious and inflammatory insults. We will also review the clinical implications of vital sign changes in neonatal sepsis, including their use in early warning scores and systems to direct clinicians to the bedside of infants with physiologic changes that might be due to sepsis. IMPACT: This manuscript summarizes and reviews the relevant literature on the physiological manifestations of neonatal sepsis and how we monitor and analyze these through vital signs and advanced analytics.
Collapse
Affiliation(s)
- Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Karen D Fairchild
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| |
Collapse
|
19
|
Hwang M, Barnewolt CE, Jüngert J, Prada F, Sridharan A, Didier RA. Contrast-enhanced ultrasound of the pediatric brain. Pediatr Radiol 2021; 51:2270-2283. [PMID: 33599780 PMCID: PMC11458139 DOI: 10.1007/s00247-021-04974-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/10/2020] [Accepted: 01/14/2021] [Indexed: 12/16/2022]
Abstract
Brain contrast-enhanced ultrasound (CEUS) is an emerging application that can complement gray-scale US and yield additional insights into cerebral flow dynamics. CEUS uses intravenous injection of ultrasound contrast agents (UCAs) to highlight tissue perfusion and thus more clearly delineate cerebral pathologies including stroke, hypoxic-ischemic injury and focal lesions such as tumors and vascular malformations. It can be applied not only in infants with open fontanelles but also in older children and adults via a transtemporal window or surgically created acoustic window. Advancements in CEUS technology and post-processing methods for quantitative analysis of UCA kinetics further elucidate cerebral microcirculation. In this review article we discuss the CEUS examination protocol for brain imaging in children, current clinical applications and future directions for research and clinical uses of brain CEUS.
Collapse
Affiliation(s)
- Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Carol E Barnewolt
- Department of Radiology, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Jörg Jüngert
- Department of Pediatrics, Friedrich-Alexander University Erlangen - Nürnberg, Erlangen, Germany
| | - Francesco Prada
- Acoustic Neuroimaging and Therapy Laboratory, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
- Focused Ultrasound Foundation, Charlottesville, VA, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Ryne A Didier
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
20
|
Carra G, Flechet M, Jacobs A, Verstraete S, Vlasselaers D, Desmet L, Van Cleemput H, Wouters P, Vanhorebeek I, Van den Berghe G, Güiza F, Meyfroidt G. Postoperative Cerebral Oxygen Saturation in Children After Congenital Cardiac Surgery and Long-Term Total Intelligence Quotient: A Prospective Observational Study. Crit Care Med 2021; 49:967-976. [PMID: 33591016 PMCID: PMC8132917 DOI: 10.1097/ccm.0000000000004852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES During the early postoperative period, children with congenital heart disease can suffer from inadequate cerebral perfusion, with possible long-term neurocognitive consequences. Cerebral tissue oxygen saturation can be monitored noninvasively with near-infrared spectroscopy. In this prospective study, we hypothesized that reduced cerebral tissue oxygen saturation and increased intensity and duration of desaturation (defined as cerebral tissue oxygen saturation < 65%) during the early postoperative period, independently increase the probability of reduced total intelligence quotient, 2 years after admission to a PICU. DESIGN Single-center, prospective study, performed between 2012 and 2015. SETTING The PICU of the University Hospitals Leuven, Belgium. PATIENTS The study included pediatric patients after surgery for congenital heart disease admitted to the PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Postoperative cerebral perfusion was characterized with the mean cerebral tissue oxygen saturation and dose of desaturation of the first 12 and 24 hours of cerebral tissue oxygen saturation monitoring. The independent association of postoperative mean cerebral tissue oxygen saturation and dose of desaturation with total intelligence quotient at 2-year follow-up was evaluated with a Bayesian linear regression model adjusted for known confounders. According to a noninformative prior, reduced mean cerebral tissue oxygen saturation during the first 12 hours of monitoring results in a loss of intelligence quotient points at 2 years, with a 90% probability (posterior β estimates [80% credible interval], 0.23 [0.04-0.41]). Similarly, increased dose of cerebral tissue oxygen saturation desaturation would result in a loss of intelligence quotient points at 2 years with a 90% probability (posterior β estimates [80% credible interval], -0.009 [-0.016 to -0.001]). CONCLUSIONS Increased dose of cerebral tissue oxygen saturation desaturation and reduced mean cerebral tissue oxygen saturation during the early postoperative period independently increase the probability of having a lower total intelligence quotient, 2 years after PICU admission.
Collapse
Affiliation(s)
- Giorgia Carra
- All authors: Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, UZ Leuven and KU Leuven, Leuven, Belgium
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Rao A, Gourkanti B, Van Helmond N. Near-Infrared Spectroscopy Monitoring in Pediatric Anesthesiology: A Pro-Con Discussion. Cureus 2021; 13:e13875. [PMID: 33868839 PMCID: PMC8043135 DOI: 10.7759/cureus.13875] [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] [Accepted: 03/14/2021] [Indexed: 11/05/2022] Open
Abstract
Near-infrared spectroscopy (NIRS) has been increasingly used as a non-invasive measurement of cerebral tissue oxygen saturation. The aim of this short review is to discuss the benefits and drawbacks of its use in the pediatric anesthesia population. In the context of cardiac surgery, lower intraoperative NIRS values have shown a modest association with neurodevelopmental outcomes while lower neonatal intensive care unit NIRS values have been correlated with reduced neurodevelopment in children. However, it is still unclear if management aimed at increasing cerebral tissue oxygenation would have any benefit on these outcomes. Without prospective research looking into the effects of intervention given proper thresholds, the true benefit of NIRS use is still up for debate. Even with current research gaps, its use in the clinical setting continues.
Collapse
Affiliation(s)
- Anusha Rao
- Anesthesiology, West Virginia University, Morgantown, USA
| | | | | |
Collapse
|
22
|
Cerebral regional oxygen saturation variability in neonates following cardiac surgery. Pediatr Res 2021; 90:815-818. [PMID: 32967003 PMCID: PMC7523257 DOI: 10.1038/s41390-020-01171-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/23/2020] [Accepted: 09/10/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reduced cerebral regional oxygen saturation (crSO2) variability in neonates, as measured by near-infrared spectroscopy, following cardiac surgery with deep hypothermic circulatory arrest (DHCA) is associated with poor neurodevelopmental outcomes. We sought to evaluate the variability of crSO2 in a cohort of neonates following cardiac surgery with brief or no exposure to DHCA. METHODS Variability of averaged 1-min crSO2 values was calculated for the first 48 h following cardiac surgery in consecutive neonates over a 30-month period. Neonates requiring aortic arch repair underwent antegrade cerebral perfusion with either brief or no exposure to DHCA. RESULTS There were 115 neonates included in the study. Reduced crSO2 variability was observed in neonates with aortic arch obstruction (p = 0.02) and non-survivors (p = 0.02). Post hoc analysis demonstrated that the reduction in crSO2 variability was not as marked as in previously studied neonates with aortic arch obstruction who received DHCA alone (p < 0.001). CONCLUSIONS Neonates with aortic arch obstruction have reduced crSO2 variability following cardiac surgery. The reduction in crSO2 variability observed in aortic arch obstruction is likely influenced by a number of factors, including perioperative perfusion technique. The impact of interventions on crSO2 variability and resultant influence on neurodevelopmental outcomes requires further study. IMPACT Neonates with aortic arch obstruction have reduced crSO2 variability following cardiac surgery, which has been associated with poor neurodevelopmental outcomes, and is likely influenced by a number of factors, including perioperative perfusion technique. The contribution of perioperative perfusion technique to crSO2 variability following neonatal cardiac surgery is significant. Monitoring of crSO2 variability may provide insights into the adequacy of cerebral perfusion in neonates following cardiac surgery.
Collapse
|
23
|
Chen S, Fang F, Liu W, Liu C, Xu F. Cerebral Tissue Regional Oxygen Saturation as a Valuable Monitoring Parameter in Pediatric Patients Undergoing Extracorporeal Membrane Oxygenation. Front Pediatr 2021; 9:669683. [PMID: 34178887 PMCID: PMC8220806 DOI: 10.3389/fped.2021.669683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/04/2021] [Indexed: 12/16/2022] Open
Abstract
Objective: Brain function monitoring technology for extracorporeal membrane oxygenation (ECMO) support has been developing quite slowly. Our objective was to explore the data distribution, variation trend, and variability of cerebral tissue regional oxygen saturation (CrSO2) in pediatric patients undergoing ECMO. Methods: Eight patients who received venoarterial ECMO (V-A ECMO) were included in our study. All of them accepted continuous CrSO2 monitoring by near-infrared spectroscopy (NIRS) within 12 h of ECMO initiation until ECMO wean. Differences in the CrSO2 distribution characteristic, the variation trend of daily CrSO2, and the variability of CrSO2 for the first 5 days following ECMO initiation were compared between survivors and non-survivors according to pediatric intensive care unit (PICU) mortality. Results: The percentage of time of CrSO2 <60% against the whole monitoring time was significantly lower in survivors in both hemispheres {right: 4.34% [interquartile range (IQR) = 0.39-8.55%] vs. 47.45% [IQR = 36.03-64.52%], p = 0.036; left: 0.40% [IQR = 0.01-1.15%] vs. 30.9% [IQR = 26.92-49.62%], p = 0.036}. Survivors had significantly higher CrSO2 on the first 4 days. Root mean of successive squared differences (RMSSD), the variability variable of CrSO2, was significantly lower in survivors (right: 3.29 ± 0.79 vs. 6.16 ± 0.67, p = 0.002; left: 3.56 ± 1.20 vs. 6.04 ± 1.44, p = 0.039). Conclusion: Lower CrSO2, CrSO2 <60% over a longer period of time, and higher fluctuation of CrSO2 are likely associated with PICU mortality in pediatric patients undergoing V-A ECMO. Clinical Trial Registry: URL: http://www.chictr.org.cn/showproj.aspx?proj=46639, trial registry number: ChiCTR1900028021.
Collapse
Affiliation(s)
- Song Chen
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Fang Fang
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Wenjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chengjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| |
Collapse
|
24
|
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]
|
25
|
Modestini M, Hoffmann L, Niezen C, Armocida B, Vos JJ, Scheeren TWL. Cerebral oxygenation during pediatric congenital cardiac surgery and its association with outcome: a retrospective observational study. Can J Anaesth 2020; 67:1170-1181. [PMID: 32557197 PMCID: PMC7299246 DOI: 10.1007/s12630-020-01733-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 03/25/2020] [Accepted: 05/01/2020] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Non-invasive cerebral oxygen saturation (ScO2) monitoring is an established tool in the intraoperative phase of pediatric congenital cardiac surgery (CCS). This study investigated the association between ScO2 and postoperative outcome by investigating both baseline ScO2 values and intraoperative desaturations from baseline. METHODS All CCS procedures performed in the period 2010-2017 in our institution in which ScO2 was monitored were included in this historical cohort study. Baseline ScO2 was determined after tracheal intubation, before surgical incision. Subgroups were based on cardiac pathology and degree of intracardiac shunting. Poor outcome was defined based on length of stay (LOS) in the intensive care unit (ICU)/hospital, duration of mechanical ventilation (MV), and 30-day mortality. Intraoperatively, ScO2 total time below baseline (TBBL) and ScO2 time-weighted average (TWA) were calculated. RESULTS Data from 565 patients were analyzed. Baseline ScO2 was significantly associated with LOS in ICU (odds ratio [OR] per percentage decrease in baseline ScO2, 0.95; 95% confidence interval [CI], 0.93 to 0.97; P < 0.001), with LOS in hospital (OR, 0.93; 95% CI, 0.91 to 0.96; P < 0.001), with MV duration (OR, 0.92; 95% CI, 0.90 to 0.95; P < 0.001) and with 30-day mortality (OR, 0.94; 95% CI, 0.91 to 0.98; P = 0.007). Cerebral oxygen saturation TWA had no associations, while ScO2 TBBL had only a small association with LOS in ICU (OR, 1.02; 95% CI, 1.01 to 1.03; P < 0.001), MV duration (OR,1.02; 95% CI, 1.01 to 1.03; P = 0.002), and LOS in hospital (OR, 1.02; 95% CI, 1.01 to 1.04; P < 0.001). CONCLUSION In pediatric patients undergoing cardiac surgery, low baseline ScO2 values measured after tracheal intubation were associated with several adverse postoperative outcomes. In contrast, the severity of actual intraoperative cerebral desaturation was not associated with postoperative outcomes. Baseline ScO2 measured after tracheal intubation may help identify patients at increased perioperative risk.
Collapse
Affiliation(s)
- Marco Modestini
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lisa Hoffmann
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- European Medical School Oldenburg-Groningen, Oldenburg, Germany
| | - Caren Niezen
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Benedetta Armocida
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jaap Jan Vos
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
26
|
The Organ-Protective Effect of Higher Partial Pressure of Arterial Carbon Dioxide in the Normal Range for Infant Patients Undergoing Ventricular Septal Defect Repair. Pediatr Cardiol 2020; 41:372-381. [PMID: 31844927 DOI: 10.1007/s00246-019-02269-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 12/07/2019] [Indexed: 10/25/2022]
Abstract
Hypercapnia has been reported to play an active role in protection against organ injury. The aim of this study was to determine whether a higher level of partial pressure of arterial carbon dioxide (PaCO2) within the normal range in pediatric patients undergoing cardiac surgery had a similar organ-protective effect. From May 2017 to May 2018, 83 consecutive infant patients undergoing ventricular septal defect (VSD) repair with cardiopulmonary bypass were retrospectively enrolled. We recorded the end-expiratory tidal partial pressure of carbon dioxide (Pet-CO2) as an indirect and continuous way to reflect the PaCO2. The patients were divided into a low PaCO2 group (LPG; 30 mmHg < Pet-CO2 < 40 mmHg) and a high PaCO2 group (HPG; 40 mmHg < Pet-CO2 < 50 mmHg). The regional cerebral oxygen saturation (rScO2), cerebral blood flow velocity (CBFV), and hemodynamics at five time points throughout the operation, and perioperative data were recorded and analyzed for the two groups. In total, 34 LPG and 49 HPG patients were included. Demographics and perioperative clinical data showed no significant difference between the groups. Compared with LPG, the HPG produced lower postoperative creatine kinase isoenzyme-MB (40.88 versus 50.34 ng/mL, P = 0.038). The postoperative C-reactive protein of HPG trended lower than in LPG (61.09 versus 73.4 mg/L, P = 0.056). The rScO2 and mean CBFV of HPG were significantly higher compared with LPG (P < 0.05) except at the end of cardiopulmonary bypass. Hemodynamic data showed no significant difference between the groups. As a convenient and safe approach, higher-normal PaCO2 could attenuate brain injury, heart injury, and inflammatory response in infant patients undergoing VSD repair.
Collapse
|
27
|
Near-Infrared-Based Cerebral Oximetry for Prediction of Severe Acute Kidney Injury in Critically Ill Children After Cardiac Surgery. Crit Care Explor 2019; 1:e0063. [PMID: 32166244 PMCID: PMC7063924 DOI: 10.1097/cce.0000000000000063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Supplemental Digital Content is available in the text. Cerebral oximetry by near-infrared spectroscopy is used frequently in critically ill children but guidelines on its use for decision making in the PICU are lacking. We investigated cerebral near-infrared spectroscopy oximetry in its ability to predict severe acute kidney injury after pediatric cardiac surgery and assessed its additional predictive value to routinely collected data.
Collapse
|
28
|
Zaleski KL, Kussman BD. Near-Infrared Spectroscopy in Pediatric Congenital Heart Disease. J Cardiothorac Vasc Anesth 2019; 34:489-500. [PMID: 31582201 DOI: 10.1053/j.jvca.2019.08.048] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 08/07/2019] [Accepted: 08/27/2019] [Indexed: 12/13/2022]
Abstract
Near-infrared spectroscopy (NIRS) is widely used to monitor tissue oxygenation in the pediatric cardiac surgical population. Clinicians who use NIRS must understand the underlying measurement principles in order to interpret and use this monitoring modality appropriately. The aims of this narrative review are to provide a brief overview of NIRS technology, discuss the normative and critical values of cerebral and somatic tissue oxygen saturation and the interpretation of these values, present the clinical studies (and their limitations) of NIRS as a perioperative monitoring modality in the pediatric congenital heart disease population, and introduce the emerging and future applications of NIRS.
Collapse
Affiliation(s)
- Katherine L Zaleski
- Department of Anesthesiology, Perioperative, and Critical Care Medicine, Division of Cardiac Anesthesia, Boston Children's Hospital, Boston, MA.
| | - Barry D Kussman
- Department of Anesthesiology, Perioperative, and Critical Care Medicine, Division of Cardiac Anesthesia, Boston Children's Hospital, Boston, MA
| |
Collapse
|
29
|
Regional tissue oxygenation monitoring in the neonatal intensive care unit: evidence for clinical strategies and future directions. Pediatr Res 2019; 86:296-304. [PMID: 31247635 DOI: 10.1038/s41390-019-0466-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/24/2019] [Accepted: 06/08/2019] [Indexed: 12/19/2022]
Abstract
Near-infrared spectroscopy (NIRS)-based monitoring of regional tissue oxygenation (rSO2) is becoming more commonplace in the neonatal intensive care unit (NICU). While increasing evidence supports rSO2 monitoring, actual standards for applying this noninvasive bedside technique continue to evolve. This review highlights the current strengths and pitfalls surrounding practical NIRS-based monitoring in the neonatal population. The physiologic background of rSO2 monitoring is discussed, with attention to understanding oxygen delivery/consumption mismatch and its effects on tissue oxygen extraction. The bedside utility of both cerebral and peripheral rSO2 monitoring in the NICU is then explored from two perspectives: (1) disease/event-specific "responsive" monitoring and (2) "routine," continuous monitoring. Recent evidence incorporating both monitoring approaches is summarized with emphasis on practical applicability in the NICU. Finally, a future paradigm for a broad-based NIRS monitoring strategy is presented, with attention towards improving personalization of neonatal care and ultimately enhancing long-term outcomes.
Collapse
|
30
|
Frogel J, Kogan A, Augoustides JG, Berkenstadt H, Feduska E, Steyn J, Dwarakanath S, Nir EA, Stohl S. The Value of Cerebral Oximetry Monitoring in Cardiac Surgery: Challenges and Solutions in Adult and Pediatric Practice. J Cardiothorac Vasc Anesth 2019; 33:1778-1784. [DOI: 10.1053/j.jvca.2018.08.206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Indexed: 02/04/2023]
|
31
|
Mahle WT. Commentary: Window of brain protection after congenital heart surgery-Is it still open? J Thorac Cardiovasc Surg 2019; 158:880-881. [PMID: 31076178 DOI: 10.1016/j.jtcvs.2019.03.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 03/15/2019] [Indexed: 11/19/2022]
Affiliation(s)
- William T Mahle
- Clinical Research Program for Cardiovascular Research, Children's Healthcare of Atlanta, Atlanta, Ga; Division of Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga.
| |
Collapse
|
32
|
Abstract
OBJECTIVES Pediatric cardiac intensive care continues to evolve, with rapid advances in knowledge and improvement in clinical outcomes. In the past, the Board of Directors of the Pediatric Cardiac Intensive Care Society created and subsequently updated a list of sentinel references focused on the care of critically ill children with congenital and acquired heart disease. The objective of this article is to provide clinicians with a compilation and brief summary of updated and useful references that have been published since 2012. DATA SELECTION Pediatric Cardiac Intensive Care Society members were solicited via a survey sent out between March 20, 2017, and April 28, 2017, to provide important references that have impacted clinical care. The survey was sent to approximately 523 members. Responses were received from 45 members, of which some included multiple references. DATA EXTRACTION Following review of the list of references, and removing editorials, references were compiled by the first and last author. The final list was submitted to members of the society's Research Briefs Committee, who ranked each publication. DATA SYNTHESIS Rankings were compiled and the references with the highest scores included. Research Briefs Committee members ranked the articles from 1 to 3, with one being highly relevant and should be included and 3 being less important and should be excluded. Averages were computed, and the top articles included in this article. The first (K.C.U.) and last author (K.M.G.) reviewed and developed summaries of each article. CONCLUSIONS This article contains a compilation of useful references for the critical care of children with congenital and acquired heart disease published in the last 5 years. In conjunction with the prior version of this update in 2012, this article may be used as an educational reference in pediatric cardiac intensive care.
Collapse
|
33
|
Near-Infrared Cerebral Oximetry to Predict Outcome After Pediatric Cardiac Surgery: A Prospective Observational Study. Pediatr Crit Care Med 2018; 19:433-441. [PMID: 29465631 DOI: 10.1097/pcc.0000000000001495] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess whether near-infrared cerebral tissue oxygen saturation, measured with the FORESIGHT cerebral oximeter (CAS Medical Systems, Branford, CT) predicts PICU length of stay, duration of invasive mechanical ventilation, and mortality in critically ill children after pediatric cardiac surgery. DESIGN Single-center prospective, observational study. SETTING Twelve-bed PICU of a tertiary academic hospital. PATIENTS Critically ill children and infants with congenital heart disease, younger than 12 years old, admitted to the PICU between October 2012 and November 2015. Children were monitored with the FORESIGHT cerebral oximeter from PICU admission until they were weaned off mechanical ventilation. Clinicians were blinded to cerebral tissue oxygen saturation data. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcome was the predictive value of the first 24 hours of postoperative cerebral tissue oxygen saturation for duration of PICU stay (median [95% CI], 4 d [3-8 d]) and duration of mechanical ventilation (median [95% CI], 111.3 hr (69.3-190.4 hr]). We calculated predictors on the first 24 hours of cerebral tissue oxygen saturation monitoring. The association of each individual cerebral tissue oxygen saturation predictor and of a combination of predictors were assessed using univariable and multivariable bootstrap analyses, adjusting for age, weight, gender, Pediatric Index of Mortality 2, Risk Adjustment in Congenital Heart Surgery 1, cyanotic heart defect, and time prior to cerebral tissue oxygen saturation monitoring. The most important risk factors associated with worst outcomes were an increased SD of a smoothed cerebral tissue oxygen saturation signal and an elevated cerebral tissue oxygen saturation desaturation score. CONCLUSIONS Increased SD of a smoothed cerebral tissue oxygen saturation signal and increased depth and duration of desaturation below the 50% saturation threshold were associated with longer PICU and hospital stays and with longer duration of mechanical ventilation after pediatric cardiac surgery.
Collapse
|
34
|
Splanchnic NIRS monitoring in neonatal care: rationale, current applications and future perspectives. J Perinatol 2018; 38:431-443. [PMID: 29472709 DOI: 10.1038/s41372-018-0075-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 11/22/2017] [Accepted: 11/28/2017] [Indexed: 12/29/2022]
Abstract
Near infrared spectroscopy (NIRS) provides a non-invasive, continuous monitoring of regional tissue oxygenation. NIRS assessment of neonatal splanchnic oxygenation (SrSO2) has gained increasing interest over the last decade, as local hypoxia and ischemia underlie the most feared gut complications in neonates. Current literature provides encouraging evidence in support of SrSO2 reliability in detecting mesenteric hemodynamic changes related to various physiological and pathological conditions in-term and preterm infants. Even so, while splanchnic NIRS monitoring looks promising for investigating gut physiopathology in research settings, further studies are needed to evaluate its feasibility as a routine monitoring tool in neonatal care and to investigate its potential role in clinical decision making. After a brief introduction to NIRS technical principles, this review aims to provide a complete overview of current neonatal applications for splanchnic NIRS monitoring, to discuss its possible limitations and to suggest future directions for research and clinical applications.
Collapse
|
35
|
Near-Infrared Spectroscopy Monitoring After Pediatric Cardiac Surgery: Time for an Intervention? Pediatr Crit Care Med 2018; 19:496-497. [PMID: 29727421 DOI: 10.1097/pcc.0000000000001504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
36
|
The authors reply. Pediatr Crit Care Med 2017; 18:500. [PMID: 28475541 DOI: 10.1097/pcc.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
37
|
Perioperative Cerebral Near-Infrared Spectroscopy Variability and Neurodevelopmental Outcomes in Congenital Heart Patients. Pediatr Crit Care Med 2017; 18:499-500. [PMID: 28475540 DOI: 10.1097/pcc.0000000000001136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|