Early Peritoneal Dialysis and Major Adverse Events After Pediatric Cardiac Surgery: A Propensity Score Analysis

An evaluation of the outcomes associated with peritoneal catheter use in neonates undergoing cardiac surgery: A multicenter study

Objective

The study objective was to determine if intraoperative peritoneal catheter placement is associated with improved outcomes in neonates undergoing high-risk cardiac surgery with cardiopulmonary bypass.

Methods

This propensity score-matched retrospective study used data from 22 academic pediatric cardiac intensive care units. Consecutive neonates undergoing Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 3 to 5 cardiac surgery with cardiopulmonary bypass at centers participating in the NEonatal and Pediatric Heart Renal Outcomes Network collaborative were studied to determine the association of the use of an intraoperative placed peritoneal catheter for dialysis or passive drainage with clinical outcomes, including the duration of mechanical ventilation.

Results

Among 1490 eligible neonates in the NEonatal and Pediatric Heart Renal Outcomes Network dataset, a propensity-matched analysis was used to compare 395 patients with peritoneal catheter placement with 628 patients without peritoneal catheter placement. Time to extubation and most clinical outcomes were similar. Postoperative length of stay was 5 days longer in the peritoneal catheter placement cohort (17 vs 22 days, P = .001). There was a 50% higher incidence of moderate to severe acute kidney injury in the no-peritoneal catheter cohort (12% vs 18%, P = .02). Subgroup analyses between specific treatments and in highest risk patients yielded similar associations.

Conclusions

This study does not demonstrate improved outcomes among neonates with placement of a peritoneal catheter during cardiac surgery. Outcomes were similar apart from longer hospital stay in the peritoneal catheter cohort. The no-peritoneal catheter cohort had a 50% higher incidence of moderate to severe acute kidney injury (12% vs 18%). This analysis does not support indiscriminate peritoneal catheter use, although it may support the utility for postoperative fluid removal among neonates at risk for acute kidney injury. A multicenter controlled trial may better elucidate peritoneal catheter effects.

Peritoneal catheters in neonates undergoing complex cardiac surgery: a multi-centre descriptive study

BACKGROUND

The use of peritoneal catheters for prophylactic dialysis or drainage to prevent fluid overload after neonatal cardiac surgery is common in some centres; however, the multi-centre variability and details of peritoneal catheter use are not well described.

METHODS

Twenty-two-centre NEonatal and Pediatric Heart Renal Outcomes Network (NEPHRON) study to describe multi-centre peritoneal catheter use after STAT category 3-5 neonatal cardiac surgery using cardiopulmonary bypass. Patient characteristics and acute kidney injury/fluid outcomes for six post-operative days are described among three cohorts: peritoneal catheter with dialysis, peritoneal catheter with passive drainage, and no peritoneal catheter.

RESULTS

Of 1490 neonates, 471 (32%) had an intraoperative peritoneal catheter placed; 177 (12%) received prophylactic dialysis and 294 (20%) received passive drainage. Sixteen (73%) centres used peritoneal catheter at some frequency, including six centres in >50% of neonates. Four centres utilised prophylactic peritoneal dialysis. Time to post-operative dialysis initiation was 3 hours [1, 5] with the duration of 56 hours [37, 90]; passive drainage cohort drained for 92 hours [64, 163]. Peritoneal catheter were more common among patients receiving pre-operative mechanical ventilation, single ventricle physiology, and higher complexity surgery. There was no association with adverse events. Serum creatinine and daily fluid balance were not clinically different on any post-operative day. Mortality was similar.

CONCLUSIONS

In neonates undergoing complex cardiac surgery, peritoneal catheter use is not rare, with substantial variability among centres. Peritoneal catheters are used more commonly with higher surgical complexity. Adverse event rates, including mortality, are not different with peritoneal catheter use. Fluid overload and creatinine-based acute kidney injury rates are not different in peritoneal catheter cohorts.

Predictors of early peritoneal dialysis initiation in newborns and young infants following cardiac surgery

OBJECTIVE

This single-centre, retrospective cohort study was conducted to investigate the predictors of early peritoneal dialysis initiation in newborns and young infants undergoing cardiac surgery.

METHODS

There were fifty-seven newborns and young infants. All subjects received peritoneal dialysis catheter after completion of the cardiopulmonary bypass. Worsening post-operative (post-op) positive fluid balance and oliguria (<1 ml/kg/hour) despite furosemide were the clinical indications to start early peritoneal dialysis (peritoneal dialysis +). Demographic, clinical, and laboratory data were collected from the pre-operative, intra-operative, and immediately post-operative periods.

RESULTS

Baseline demographic data were indifferent except that peritoneal dialysis + group had more newborns. Pre-operative serum creatinine was higher for peritoneal dialysis + group (p = 0.025). Peritoneal dialysis + group had longer cardiopulmonary bypass time (p = 0.044), longer aorta cross-clamp time (p = 0.044), and less urine output during post-op 24 hours (p = 0.008). In the univariate logistic regression model, pre-op serum creatinine was significantly associated with higher odds of being in peritoneal dialysis + (p = 0.021) and post-op systolic blood pressure (p = 0.018) and post-op mean arterial pressure (p=0.001) were significantly associated with reduced odds of being in peritoneal dialysis + (p = 0.018 and p = 0.001, respectively). Post-op mean arterial pressure showed a statistically significant association adjusted odds ratio = 0.89, 95% confidence interval [0.81, 0.96], p = 0.004) with peritoneal dialysis + in multivariate analysis after adjusting for age at surgery.

CONCLUSIONS

In our single-centre cohort, pre-op serum creatinine, post-op systolic blood pressure, and mean arterial pressure demonstrated statistically significant association with peritoneal dialysis +. This finding may help to better risk stratify newborns and young infants for early peritoneal dialysis start following cardiac surgery.

Early Peritoneal Dialysis and Postoperative Outcomes in Infants After Pediatric Cardiac Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

Peritoneal dialysis (PD) is used in several cardiac surgical units after cardiac surgery, and early initiation of PD after surgery may have the potential to influence postoperative outcomes. This systematic review and meta-analysis aims to summarize the evidence for the association between early PD after cardiac surgery and postoperative outcomes.

DATA SOURCES

MEDLINE, Embase, and PubMed from 1981 to November 1, 2021.

STUDY SELECTION

Observational studies and randomized trials reporting on early PD after pediatric cardiac surgery.

DATA EXTRACTION

Random-effects meta-analysis was used to estimate the pooled odds ratios (ORs) and their 95% CIs for postoperative mortality and pooled mean difference (MD) (95% CI) for duration of mechanical ventilation and ICU length of stay.

DATA SYNTHESIS

We identified nine studies from the systematic review, and five were considered suitable for meta-analysis. Early initiation of PD after cardiac surgery was associated with a reduction in postoperative mortality (OR, 0.43 (95% CI, 0.23-0.80); number of estimates = 4). Early commencement of PD shortened duration of mechanical ventilation (MD [95% CI], -1.09 d [-1.86 to -0.33 d]; I2 = 56.1%; p = 0.06) and intensive care length of stay (MD [95% CI], -2.46 d [-3.57 to -1.35 d]; I2 = 18.7%; p = 0.30], respectively. All three estimates had broad 95% prediction intervals (crossing null) denoting major heterogeneity between studies and wide range of possible study estimates in similar future studies. Overall, studies reporting on the effects of early PD included only a subset of infants undergoing cardiac surgery (typically high-risk infants), so selection bias may be a major issue in published studies.

CONCLUSIONS

This review suggests that early initiation of PD may be associated with beneficial postoperative outcomes in infants after cardiac surgery. However, these results were based on studies of varying qualities and risk of bias. Early identification of high-risk infants after cardiac surgery is important so that prevention or early mitigation strategies can be applied to this cohort. Future prospective studies in high-risk populations are needed to study the role of early PD in influencing postoperative outcomes.

Study protocol and statistical analysis plan for the Early Peritoneal Dialysis in Infants after Cardiac Surgery (EPICS) trial

Background: Peritoneal dialysis (PD) is a commonly used therapy after infant cardiac surgery. It is unclear whether early PD commenced soon after admission to an intensive care unit (ICU) after cardiac surgery results in better outcomes. Objective: To describe the study protocol and statistical analysis plan for the Early Peritoneal Dialysis in Infants after Cardiac Surgery (EPICS) trial. Design, setting, participants and intervention: The EPICS trial is an open, randomised, two-group, single-centre clinical study of infants ≤ 180 days of age who had cardiac surgery (in Risk-Adjusted Classification for Congenital Heart Surgery version 1 categories 3-6) with cardiopulmonary bypass. Participants will be randomly assigned 1:1 to early PD (treatment group) or no early PD (control group). Those assigned to the treatment group will begin receiving PD soon after ICU admission and continue receiving it for 24 hours. Those in the control group will not receive PD during the first 24 hours. Main outcome measures: The primary outcome is a composite measure consisting of one or more of death, cardiac arrest, emergency chest reopening, and requirement for extracorporeal membrane oxygenation (ECMO) within 90 days. The main secondary outcomes are duration of mechanical ventilation, ICU length of stay, hospital length of stay, vasoactive-inotropic score at 24 hours, and cumulative per cent fluid balance by end of Day 2. At Day 90, events such as mortality, requirement for ECMO, cardiac arrest, chest reopening, volume of packed red blood cell transfusion, postoperative infection, readmission to ICU, renal injury and brain injury will be assessed. Conclusions: The EPICS trial aims to evaluate the role of early PD after infant cardiac surgery in lowering the rate of a composite major outcome. In addition, it will test the effect of early PD on duration of mechanical ventilation, and on ICU and hospital length of stay. Trial registration: ACTRN12617001614381.

Evaluation of postoperative renal functions and its effect on body perfusion in patients with double aortic cannulation

BACKGROUND

The optimal visceral preservation method during aortic arch reconstruction is still controversial. It has been thought that double aortic cannulation is effective. Herein, it was aimed to evaluate this technique in providing distal perfusion.

METHODS

A total of 74 patients who underwent arch reconstruction between 2011 and 2019 were included. Patients were grouped according to ventricular physiology and cannulation strategies. Group 1 were univentricle patients, and all had double aortic cannulation. Group 2 were biventricular patients. Group 2A double aortic cannulation-done and Group 2B non-double aortic cannulation were included. Lactate, urea, creatinine values, renal functions, and need for peritoneal dialysis of patients were evaluated.

RESULTS

There were no complications observed due to descending aortic cannulation in any of the patients. A delayed sternal closure and the need for peritoneal dialysis were more common in the Group 1 (p < 0.01). The preoperative and postoperative 1st- and 2nd-day lactate, urea, and creatinine values in the Group 1 were higher (p < 0.05) when compared with the Group 2A and 2B. The same values were higher in Group 2A than the Group 2B (p < 0.05).

CONCLUSION

The positive effect of double aortic cannulation on renal dysfunction could not be demonstrated. This may be associated with a <1 month of age, low weight, complex surgical procedure, and high preoperative lactate, urea, and creatinine values in patients with double aortic cannulation.

LA, Vasudevan A. Peritoneal Dialysis with Rigid Catheters in Children with Acute Kidney Injury: A Single-Centre Experience

Peritoneal dialysis (PD) is a simple and preferred modality of dialysis for children with acute kidney injury (AKI) in resource poor countries. The aim of the study is to evaluate the utility and safety of acute PD using rigid catheter in critically ill children admitted to pediatric intensive care unit (PICU) with emphasis on short-term patient and renal outcome and complications. In this retrospective study, outcome and complications of PD using rigid catheter were evaluated in 113 critically ill children admitted in PICU of a tertiary care hospital from 2014 to 2019. The most common causes for AKI were sepsis (39.8%), dengue infection (16.8%), and hemolytic uremic syndrome (13.2%). In 113 patients, 122 PD catheters were inserted, and the median duration of PD was 60 (IQR: 36–89) hours. At the initiation of PD, 64 (56.6%) patients were critically ill requiring mechanical ventilation and inotropes, 26 (23%) had disseminated intravascular coagulation, and 42 (37%) had multiorgan dysfunction syndrome. PD was effective and there was a significant improvement in urea and creatinine, and one-third patients (n = 38; 33.6%) had complete renal recovery at the end of PD. Total complications were seen in 67% children but majority of them were metabolic (39.8%). Total catheter related complications were seen in 21.2% and peritonitis was seen in 4.4%. Catheter removal due to complications was required in 8.8% children. Overall, among children on PD, 53.7% survived. Acute PD with rigid catheters can be performed bedside in absence of soft catheters and significant clearance can be obtained without major life-threatening complications.

Predicting and Surviving Prolonged Critical Illness After Congenital Heart Surgery

OBJECTIVES

Prolonged critical illness after congenital heart surgery disproportionately harms patients and the healthcare system, yet much remains unknown. We aimed to define prolonged critical illness, delineate between nonmodifiable and potentially preventable predictors of prolonged critical illness and prolonged critical illness mortality, and understand the interhospital variation in prolonged critical illness.

DESIGN

Observational analysis.

SETTING

Pediatric Cardiac Critical Care Consortium clinical registry.

PATIENTS

All patients, stratified into neonates (≤28 d) and nonneonates (29 d to 18 yr), admitted to the pediatric cardiac ICU after congenital heart surgery at Pediatric Cardiac Critical Care Consortium hospitals.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 2,419 neonates and 10,687 nonneonates from 22 hospitals. The prolonged critical illness cutoff (90th percentile length of stay) was greater than or equal to 35 and greater than or equal to 10 days for neonates and nonneonates, respectively. Cardiac ICU prolonged critical illness mortality was 24% in neonates and 8% in nonneonates (vs 5% and 0.4%, respectively, in nonprolonged critical illness patients). Multivariable logistic regression identified 10 neonatal and 19 nonneonatal prolonged critical illness predictors within strata and eight predictors of mortality. Only mechanical ventilation days and acute renal failure requiring renal replacement therapy predicted prolonged critical illness and prolonged critical illness mortality in both strata. Approximately 40% of the prolonged critical illness predictors were nonmodifiable (preoperative/patient and operative factors), whereas only one of eight prolonged critical illness mortality predictors was nonmodifiable. The remainders were potentially preventable (postoperative critical care delivery variables and complications). Case-mix-adjusted prolonged critical illness rates were compared across hospitals; six hospitals each had lower- and higher-than-expected prolonged critical illness frequency.

CONCLUSIONS

Although many prolonged critical illness predictors are nonmodifiable, we identified several predictors to target for improvement. Furthermore, we observed that complications and prolonged critical care therapy drive prolonged critical illness mortality. Wide variation of prolonged critical illness frequency suggests that identifying practices at hospitals with lower-than-expected prolonged critical illness could lead to broader quality improvement initiatives.

Core-Peripheral Temperature Gradient and Skin Temperature as Predictors of Major Adverse Events Among Postoperative Pediatric Cardiac Patients

OBJECTIVE

During episodes of low cardiac output, sympathetic neurohumoral responses with peripheral vasoconstriction result in an increase in the core-peripheral temperature gradient (CPTG). However, assessment of CPTG as a surrogate of low cardiac output and a predictor of outcomes in pediatric cardiac patients rarely has been performed. In this retrospective study, the authors assessed the prognostic abilities of CPTG, skin temperature, and serum lactate level for predicting clinical outcomes.

DESIGN

A retrospective single-center study.

SETTING

Referral high-volume pediatric center.

PATIENTS

Patients younger than four months of age with congenital heart disease who underwent cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was a composite of one or more of the following major adverse events (MAEs) that occurred within seven days after surgery: death from any cause, cardiac arrest, emergency chest reopening, and requirement for extracorporeal membrane oxygenation. A total of 661 patients were included in the study. Univariate logistic regression analyses showed no significant difference in the odds for MAEs with CPTG at admission and at six hours after surgery and in the odds for MAEs with skin temperature at admission. On the other hand, the odds for MAEs increased significantly with increase in serum lactate level at admission (odds ratio [OR]: 1.54, 95% confidence interval [CI]: 1.26-1.87, p < 0.001) and at six hours after surgery (OR: 1.94, 95% CI: 1.50-2.51, p < 0.001). Areas under the receiver operating curve at admission for predicting MAEs were 0.531 for CPTG, 0.557 for skin temperature, and 0.713 for serum lactate. Multivariate logistic regression analysis showed neither CPTG nor skin temperature at any time point was significantly associated with MAEs.

CONCLUSIONS

Both CPTG and skin temperature had low performance for prediction of MAEs in children after cardiac surgery. Either of those markers, especially at admission, should not be used as a single marker for assessing the condition of a patient.

Development of acute kidney injury following pediatric cardiac surgery

Acute kidney injury (AKI) in the pediatric population is a relatively common phenomenon. Specifically, AKI has been found in increasing numbers within the pediatric population following cardiac surgery, with up to 43% of pediatric patients developing AKI post-cardiac surgery. However, recent advances have allowed for the identification of risk factors. These can be divided into preoperative, intraoperative, and postoperative factors. Although the majority of pediatric patients developing AKI after cardiac surgery completely recover, this condition is associated with worse outcomes. These include fluid overload and increased mortality and result in longer hospital and intensive care unit stays. Detecting the presence of AKI has advanced; use of relatively novel biomarkers, including neutrophil gelatinase associated lipocalin, has shown promise in detecting more subtle changes in kidney function when compared to conventional methods. While a single, superior treatment has not been elucidated yet, novel functions of medications, including fenoldopam, theophylline and aminophylline, have been shown to have better outcomes for these patients. With the recent advances in identification of risk factors, outcomes, diagnosis, and management, the medical community can further explain the complexities of AKI in the pediatric population post-cardiac surgery.

Changing the terminology from kidney replacement therapy to kidney support therapy

Kidney replacement therapy (KRT) is a common supportive treatment for renal dysfunction, especially acute kidney injury. However, critically ill or immunosuppressed patients with renal dysfunction often have dysfunction in other organs as well. To improve patient outcomes, clinicians began to initiate kidney replacement therapy in situations where nonrenal conditions may lead to acute kidney injury, such as septic shock, hematopoietic stem cell transplantation, veno-occlusive renal disease, cardiopulmonary bypass, chemotherapy, tumor lysis syndrome, hyperammonemia, and various others. In this review, we discuss the use of various modes of kidney replacement therapy in treating renal and nonrenal complications to illustrate why kidney support therapy is a more appropriate terminology than kidney replacement therapy.

Prevalence and predictors of postoperative peritoneal dialysis in infants

BACKGROUND

Data regarding predictors of the eventual need for postoperative peritoneal dialysis in infants undergoing open heart surgery is still limited. We aimed to determine whether prolonged cardiopulmonary bypass time, surgical complexity classified according to Risk Adjustment for Congenital Heart Surgery category, younger age, and lower body weight increase the probability of requiring postoperative peritoneal dialysis.

METHODS

We retrospectively analyzed data of 181 infants who underwent open heart surgery at our institution from January 1 to December 31, 2018. Cardiopulmonary bypass time, Risk Adjustment for Congenital Heart Surgery category, age, body weight, and the need for postoperative peritoneal dialysis were recorded and analyzed.

RESULTS

Thirteen (7.2%) of the 181 patients required postoperative peritoneal dialysis. This group was found to have a longer cardiopulmonary bypass time, younger age, and lower body weight. Longer cardiopulmonary bypass time (p = 0.001), higher Risk Adjustment for Congenital Heart Surgery category (p = 0.018), younger age (p < 0.001), and lower body weight (p < 0.001) significantly increased the risk of postoperative peritoneal dialysis.

CONCLUSION

Longer cardiopulmonary bypass time, more complex surgery, younger age, and lower body weight increase the probability of requiring postoperative peritoneal dialysis in infants undergoing open heart surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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