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McGetrick ME, Riviello JJ. Neurological injury in pediatric heart disease: A review of developmental and acquired risk factors and management considerations. Semin Pediatr Neurol 2024; 49:101115. [PMID: 38677794 DOI: 10.1016/j.spen.2024.101115] [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: 10/16/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 04/29/2024]
Abstract
Medical and surgical advancements have improved survival in children with acquired and congenital heart disease (CHD), but the burden of neurological morbidity is high. Brain disorders associated with CHD include white matter injury, stroke, seizure, and neurodevelopmental delays. While genetics and disease-specific factors play a substantial role in early brain injury, therapeutic management of the heart disease intensifies the risk. There is a growing interest in understanding how to reduce brain injury and improve neurodevelopmental outcomes in cardiac diseases. Pediatric neurologists serve a vital role in care teams managing these complex patients, providing interpretation of neuromonitoring and imaging, managing neurologic emergencies, assisting with neuro prognostication, and identifying future research aims.
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Affiliation(s)
- Molly E McGetrick
- Division of Cardiology and Critical Care, Department of Pediatrics, the University of Texas Southwestern, Children's Medical Center, Dallas, Texas, USA.
| | - James J Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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Jock A, Neunhoeffer F, Rörden A, Schuhmann MU, Zipfel J, Hofbeck M, Dietzel M, Scherer S, Urla C, Fuchs J, Michel J, Fideler F. The effect of intraoperative cerebral oxygen desaturations on postoperative cerebral oxygen metabolism in neonates and infants a pilot study. Paediatr Anaesth 2024; 34:138-144. [PMID: 37933584 DOI: 10.1111/pan.14789] [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: 04/24/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Cerebral oxygen desaturation during pediatric surgery has been associated with adverse perioperative outcomes. The aim of this pilot study was to analyze the frequency and severity of intraoperative cerebral oxygen desaturations and their impact on postoperative cerebral oxygen metabolism in neonates and infants undergoing pediatric surgery. METHODS In a prospective pilot study, intra- and postoperative regional cerebral oxygen saturation and blood flow were measured noninvasively using a device combining laser Doppler flowmetry and white-light-spectrometry. Thirty-seven consecutive neonates and infants undergoing noncardiac surgery under general anesthesia for more than 30 min and necessity for invasive arterial blood pressure monitoring were included. Patients with pre-known congenital structural heart disease or cerebral disease were excluded. Continuously brain monitor recording was started in sedated patients before induction of anesthesia (preoperative baseline) and was completed 1 h postoperatively in the PICU in sedated, intubated, and mechanically ventilated states at the PICU (postoperative state). Baseline and postoperative state for cerebral fractional tissue oxygen extraction and approximated cerebral metabolic rate of oxygen were calculated. RESULTS Seventeen (46%) of the 37 studied neonates and infants suffered from intraoperative periods of regional cerebral oxygen desaturation below 20% of the baseline (event group). Severity of cerebral desaturations was median 4.0%min/h [range 0.1-58.7; interquartile range [IQR] 0.99-21.29]. In the event group, the duration of surgery was significantly longer (median 135 min [range 11-260; IQR 113.5-167.0] vs median 46.5 min [range 11-180; IQR 30.5-159.3]; difference of -62.94; 95% confidence interval [CI] -105.17 to -20.71; p = .021). In the event group, cerebral fractional tissue oxygen extraction (median 0.41 [range 0.20-0.55; IQR 0.26-0.44] vs. median 0.27 [range 0.11-0.41; IQR 0.20-0.31]; difference of -0.11; 95% CI -0.17 to -0.05; p = .001) and approximated cerebral metabolic rate of oxygen (median 6.15 arbitrary unit [range 2.69-12.07; IQR 5.12-7.21] vs. median 4.14 arbitrary unit [range 1.78-7.86; IQR 3.82-6.31]; difference of -1.76; 95% CI -3.03 to -0.49; p = .009) were significantly higher and the cerebral regional oxygen saturation (median 58.99% [range 44.87-79.1; IQR 54.26-72.61] vs median 70.94% [range 57.9-86.13; IQR 67.07-76.59]; difference of 10.01; 95% CI 4.13-15.90; p = .002) significantly lower after surgery compared to the nonevent group. DISCUSSION The increase of approximated cerebral metabolic rate of oxygen could indicate an elevated oxidative energy metabolism in the "stressed" brain, due to repair processes. The increased cerebral fractional tissue oxygen extraction fits with the decreased NIRS cerebral oxygenation. Our data suggest that an increase in cerebral oxygen metabolism was the cause. CONCLUSION Cerebral oxygen desaturation during major surgery in neonates and infants is associated with early postoperative increased cerebral oxygen extraction and possibly increased cerebral oxygen metabolism.
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Affiliation(s)
- Anna Jock
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Alisa Rörden
- Department of Dermatology, University Hospital, Tuebingen, Germany
| | - Martin U Schuhmann
- Department of Pediatric Neurosurgery, University Hospital, Tuebingen, Germany
| | - Julian Zipfel
- Department of Pediatric Neurosurgery, University Hospital, Tuebingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Markus Dietzel
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
| | - Simon Scherer
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
| | - Cristian Urla
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Frank Fideler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tuebingen, Germany
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Magunia H, Nester J, Sandoval Boburg R, Schlensak C, Rosenberger P, Hofbeck M, Keller M, Neunhoeffer F. Abdominal and Peripheral Tissue Oxygen Supply during Selective Lower Body Perfusion for the Surgical Repair of Congenital Heart Disease: A Pilot Study. J Cardiovasc Dev Dis 2022; 9:jcdd9120436. [PMID: 36547433 PMCID: PMC9782002 DOI: 10.3390/jcdd9120436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/22/2022] [Accepted: 12/02/2022] [Indexed: 12/11/2022] Open
Abstract
Background: Lower body perfusion (LBP) may be a strategy for maintaining organ perfusion during congenital heart disease surgery. It is hypothesized that renal and lower limb oxygen supply during LBP is superior to off-pump surgery and comparable to that of a standard cardiopulmonary bypass (CPB). Methods: in this prospective single-center study, patients aged <1 year were recruited if they were scheduled for a correction of aortic arch anomalies using antegrade cerebral perfusion and LBP (group 1), a repair of coarctation during aortic cross-clamping (group 2), or surgery under whole-body CPB (group 3). Renal (prefix “r”) and peripheral (prefix “p”) oxygen saturation (SO2), hemoglobin amount (Hb), blood velocity (Velo), and blood flow (Flow) were measured noninvasively. Results: A total of 23 patients were included (group 1, n = 9; group 2, n = 5; group 3, n = 9). Compared to the baseline values, rSO2 and pSO2 decreased significantly in group 2 compared to groups 1 and 3. Conversely, rHB significantly increased in group 2 compared to groups 1 and 3, reflecting abdominal venous stasis. Compared to group 3, group 1 showed a significantly lower pFlow during CPB; however, rFlow, pFlow, and pVelo did not differ. Conclusion: according to these observations, LBP results in an improved renal oxygen supply compared to off-pump surgery and may prove to be a promising alternative to conventional CPB.
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Affiliation(s)
- Harry Magunia
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany
| | - Jana Nester
- Department of Cardiovascular and Thoracic Surgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany
| | - Rodrigo Sandoval Boburg
- Department of Cardiovascular and Thoracic Surgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany
| | - Christian Schlensak
- Department of Cardiovascular and Thoracic Surgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Intensive Care Medicine, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 1, 72076 Tuebingen, Germany
| | - Marius Keller
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany
- Correspondence: ; Tel.: +49-(0)7071-2986564; Fax: +49-(0)7071-295533
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Intensive Care Medicine, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 1, 72076 Tuebingen, Germany
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