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Schindler E, Karlsson J, Engelhardt T. Of storks and babies and secondary analyses. Acta Anaesthesiol Scand 2024; 68:718-719. [PMID: 38511234 DOI: 10.1111/aas.14410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/23/2024] [Accepted: 03/07/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Ehrenfried Schindler
- Department for Anesthesiology and Intensive Care Medicine (KAI), Section Pediatric Anesthesiology, University of Bonn, University Hospital (UKB), Bonn, Germany
| | - Jacob Karlsson
- Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Engelhardt
- Department of Anesthesia, Montreal Children's Hospital and McGill University, Montreal, Canada
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2
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Thorlacius EM, Keski-Nisula J, Vistnes M, Ojala T, Molin M, Synnergren M, Romlin BS, Ricksten SE, Wåhlander H, Castellheim AG. High-sensitive troponinT, interleukin-8, and interleukin-6 link with post-surgery risk in infant heart surgery. Acta Anaesthesiol Scand 2024; 68:745-752. [PMID: 38531618 DOI: 10.1111/aas.14405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND This study focuses on biomarkers in infants after open heart surgery, and examines the association of high-sensitive troponin T (hs-cTnT), interleukin-6 (IL-6), and interleukin-8 (IL-8) with postoperative acute kidney injury (AKI), ventilatory support time and need of vasoactive drugs. METHODS Secondary exploratory study from a double-blinded clinical randomized trial (Mile-1) on 70 infants undergoing open heart surgery with cardiopulmonary bypass (CPB). In this sub-study, the entire study population was examined without considering the study drugs. The biomarkers' peak concentration (highest concentration at 2 or 6 h post-CPB) were used for statistical analyses. RESULTS Peak IL-8, hs-cTnT, and IL-6 occurred at 2 h post-CPB for 96%, 79%, and 63% of the patients, respectively. The odds ratio of developing AKI2-3 for IL-6 > 293 pg/mL was 23.4 (95% CI 5.3;104.0), for IL-8 > 100 pg/mL it was 11.5 (3.0;44.2), and for hs-cTnT >5597 pg/mL it was 6.1 (1.5; 24.5). In more than two third of the patients with the highest peak concentrations of IL-8, IL-6, and hs-cTnT, there was a need for ventilatory support for >24 h and use of vasoactive drugs at 24 h post-CPB, while in less than one third of the patients with the lowest peak concentrations of IL-8 and hs-cTnT such requirements were observed. CONCLUSIONS The peak biomarker concentrations and CPB-time strongly predicted AKI2-3, with IL-6 and IL-8 emerging as strongest predictors. Furthermore, our findings suggest that measuring hs-cTnT and IL-8 just 2 h post-CPB-weaning may assist in identifying infants suitable for early extubation and highlight those at risk of prolonged ventilation.
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Affiliation(s)
- Elin M Thorlacius
- Department of Anesthesiology and Intensive Care medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Juho Keski-Nisula
- Department of Anesthesia and Intensive Care, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Maria Vistnes
- Department of Internal Medicine, Diakonhjemmet Hospital and Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Tiina Ojala
- Department of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | | | - Mats Synnergren
- Department of Pediatric Thoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Birgitta S Romlin
- Department of Anesthesiology and Intensive Care medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Håkan Wåhlander
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Pediatric Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Albert Gyllencreutz Castellheim
- Department of Anesthesiology and Intensive Care medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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Joshi RK, Joshi R, Aggarwal N, Agarwal M, Siddartha CR, Relan J, Kumar A, Modi M, Chug P. Comparison of Levosimendan Versus Milrinone After the Arterial Switch Operation for Infants ≤3 kg. World J Pediatr Congenit Heart Surg 2024:21501351241239306. [PMID: 38766718 DOI: 10.1177/21501351241239306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Background: Various inotropes and inodilators have been utilized to treat low cardiac output syndrome after the arterial switch operation. The use of levosimendan, a calcium sensitizer has been limited in this setting. This study compares the effects of levosimendan with milrinone in managing low cardiac output after the arterial switch operation. Methods: A retrospective, comparative study was conducted in a tertiary care hospital on patients weighing up to 3 kg undergoing the arterial switch operation between January 2017 and January 2022. Patients received a loading dose followed by continuous infusion of either levosimendan or milrinone. Echocardiographic, hemodynamic and biochemical parameters were compared. Results: Forty-three patients received levosimendan and 42 patients received milrinone as the primary test drug. Cardiac index of less than 2.2 L/min/m2 on postoperative day 1 and 2 was found in 9.3% and 2.3% of patients receiving levosimendan versus 26.2% and 11.9% in those receiving milrinone, respectively (P = .04 and .08, respectively). Early lactate-clearance and better central venous oxygen saturations were noted in the levosimendan group. Prevalence of acute kidney injury was higher in the milrinone group (50% vs 28%; P = .03). Use of peritoneal dialysis in the milrinone group versus levosimendan was 31% and 16.3%, respectively (P = .11). There was no difference in hospital mortality between the groups (milrinone, 3; levosimendan, 2, P = .62). Conclusions: Levosimendan is safe and as effective as milrinone to treat low cardiac output syndrome occurring in neonates after the arterial switch operation. In addition we found that levosimendan was renal protective when compared with milrinone.
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Affiliation(s)
- Reena Khantwal Joshi
- Division of Pediatric Cardiac Anesthesia, Sir Ganga Ram Hospital, New Delhi, India
| | - Raja Joshi
- Division of Pediatric Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Neeraj Aggarwal
- Division of Pediatric Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Mridul Agarwal
- Division of Pediatric Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Jay Relan
- Division of Pediatric Cardiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil Kumar
- Division of Pediatric Cardiac Intensive Care, Sir Ganga Ram Hospital, New Delhi, India
| | - Manoj Modi
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Parul Chug
- Department of Biotechnology & Research, Sir Ganga Ram Hospital, New Delhi, India
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4
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Thorlacius EM, Castellheim AG. Unraveling the inflammatory narrative: A rejoinder to a curious tale. Acta Anaesthesiol Scand 2024. [PMID: 38745391 DOI: 10.1111/aas.14432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Elin M Thorlacius
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Albert Gyllencreutz Castellheim
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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Matsushita FY, Krebs VLJ, de Campos CV, de Vincenzi Gaiolla PV, de Carvalho WB. Reassessing the role of milrinone in the treatment of heart failure and pulmonary hypertension in neonates and children: a systematic review and meta-analysis. Eur J Pediatr 2024; 183:543-555. [PMID: 37999764 DOI: 10.1007/s00431-023-05342-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023]
Abstract
To evaluate milrinone's impact on pediatric cardiac function, focusing on its specific role as an inotrope and lusitrope, while considering its systemic and pulmonary vasodilatory effects. Search of PubMed, EMBASE, and the Cochrane Library up to August 2023. We included all studies that evaluated milrinone in children under 18 years old in neonatal, pediatric, or cardiac intensive care units. We excluded case reports, studies that did not provide tabular information on milrinone's outcomes, and studies focused on non-intensive care populations. We extracted data on the research design, objectives, study sample, and results of each study, including the impact of milrinone and any associated factors. We screened a total of 9423 abstracts and 41 studies were ultimately included. Milrinone significantly improved left ventricular ejection fraction (WMD 3.41 [95% CI 0.61 - 6.21]), left ventricle shortening fraction (WMD 4.25 [95% CI 3.43 - 5.08]), cardiac index (WMD 0.50 [95% CI 0.32 to 0.68]), left ventricle output (WMD 55.81 [95% CI 4.91 to 106.72]), serum lactate (WMD -0.59 [95% CI -1.15 to -0.02]), and stroke volume index (WMD 2.95 [95% CI 0.09 - 5.82]). However, milrinone was not associated with improvements in ventricular myocardial performance index (WMD -0.01 [95% CI -0.06 to 0.04]) and ventricular longitudinal strain (WMD -2.14 [95% CI -4.56 to 0.28]). Furthermore, milrinone was not associated with isovolumetric relaxation time reduction (WMD -8.87 [95% CI -21.40 to 3.66]). CONCLUSION Our meta-analysis suggests potential clinical benefits of milrinone by improving cardiac function, likely driven by its systemic vasodilatory effects. However, questions arise about its inotropic influence and the presence of a lusitropic effect. Moreover, milrinone's pulmonary vasodilatory effect appears relatively weaker compared to its systemic actions. Further research is needed to elucidate milrinone's precise mechanisms and refine its clinical applications in pediatric practice. WHAT IS KNOWN • Milrinone is a phosphodiesterase III inhibitor that has been used to treat a variety of pediatric and neonatal conditions. • Milrinone is believed to exert its therapeutic effects by enhancing cardiac contractility and promoting vascular relaxation. WHAT IS NEW • Milrinone may not have a significant inotropic effect. • Milrinone's pulmonary vasodilatory effect is less robust than its systemic vasodilatory effect.
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Affiliation(s)
- Felipe Yu Matsushita
- Department of Pediatrics, Neonatology Division, Faculty of Medicine of the University of São Paulo, Instituto da Criança, Av. Dr. Enéas de Carvalho Aguiar, 647, São Paulo, 05403-000, Brazil.
- Department of Pediatric Cardiology, Faculty of Medicine of the University of São Paulo, Instituto do Coração, São Paulo, Brazil.
- Department of Pediatrics and Neonatology, Hospital Samaritano, São Paulo, São Paulo, Brazil.
| | - Vera Lúcia Jornada Krebs
- Department of Pediatrics, Neonatology Division, Faculty of Medicine of the University of São Paulo, Instituto da Criança, Av. Dr. Enéas de Carvalho Aguiar, 647, São Paulo, 05403-000, Brazil
| | - Carolina Vieira de Campos
- Department of Pediatric Cardiology, Faculty of Medicine of the University of São Paulo, Instituto do Coração, São Paulo, Brazil
| | | | - Werther Brunow de Carvalho
- Department of Pediatrics, Neonatology Division, Faculty of Medicine of the University of São Paulo, Instituto da Criança, Av. Dr. Enéas de Carvalho Aguiar, 647, São Paulo, 05403-000, Brazil
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Costigan C, Balgobin S, Zappitelli M. Drugs in treating paediatric acute kidney injury. Pediatr Nephrol 2023; 38:3923-3936. [PMID: 37052689 DOI: 10.1007/s00467-023-05956-4] [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: 01/03/2023] [Revised: 03/03/2023] [Accepted: 03/17/2023] [Indexed: 04/14/2023]
Abstract
Acute kidney injury (AKI) is a complex syndrome which affects a significant proportion of hospitalized children. The breadth and impact of AKI on health outcomes in both adults and children have come to the fore in recent years with increasing awareness encouraging research advancement. Despite this, management strategies for most types of AKI remain heavily reliant on fluid and electrolyte management, hemodynamic optimization, nephrotoxin avoidance and appropriate initiation of kidney replacement therapy. Specific drugs targeting the mechanisms involved in AKI remain elusive. Recent improvement in appreciation of the complexity of AKI pathophysiology has allowed for greater opportunity to consider novel therapeutic agents. A number of drugs specifically targeting AKI are in various stages of development. This review will consider some novel and repurposed agents; interrogate the plausibility of the proposed mechanisms of action, as they relate to what we know about the pathophysiology of AKI; and review the level of existing literature supporting their efficacy. The evidence base, particularly in children, is limited.
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Affiliation(s)
- Caoimhe Costigan
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Steve Balgobin
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Michael Zappitelli
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
- Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th floor, Rm 11.9722, Toronto, ON, M5G 0A4, Canada.
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Shao W, Diao S, Zhou L, Cai L. Milrinone for the treatment of heart failure caused by severe Pneumonia in children with congenital heart disease: a meta-analysis. BMC Pediatr 2023; 23:537. [PMID: 37891490 PMCID: PMC10612214 DOI: 10.1186/s12887-023-04360-z] [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: 12/19/2022] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Children with congenital heart disease (CHD) are easily complicated by severe pneumonia and heart failure. We aimed to conduct a meta-analysis to evaluate the effects and safety of milrinone for the treatment of heart failure caused by severe pneumonia in children with CHD to provide evidence for the clinical CHD treatment. METHODS Two authors searched MEDLINE, PubMed, Embase, Science Direct, Cochrane Central Register of Controlled Trials, the Cochrane Library, Wanfang database, Chinese Biomedical Literature Database, China National Knowledge Infrastructure (CNKI) for randomized controlled trials (RCTs) about the application of milrinone in the treatment of heart failure caused by severe pneumonia in children with CHD in children up to December 10, 2022. Two evaluators independently selected the literature, extracted data and evaluated the methodological quality, meta-analysis was carried out with RevMan 5.3 software. RESULTS Eight RCTs involving 680 CHD children complicated by severe pneumonia and heart failure were included in this meta-analysis. Meta-analysis indicated that total effective rate of the milrinone group was higher than that of control group (RR = 1.25, 95%CI: 1.17 ~ 1.34, P < 0.001), the time to stable heart rate of the milrinone group was less than that of control group (RR=-0.88, 95%CI: -1.09~ -0.67, P < 0.001). The time to stable respiration of the milrinone group was less than that of control group (RR=-0.98, 95%CI: -1.17~ -0.78, P < 0.001). The LVEF of the milrinone group was higher than that of control group (RR = 6.46, 95%CI: 5.30 ~ 7.62, P < 0.001). There was no significant difference in the incidence of adverse reactions between the milrinone group and control group (RR = 0.85, 95%CI: 0.47 ~ 1.56, P = 0.061). Funnel plots and Egger regression test results indicated that there were no statistical publication bias amongst the synthesized outcomes (all P > 0.05). CONCLUSIONS Milrinone is beneficial to improve clinical symptoms and cardiac function and increase the therapeutic effect and safety in children with CHD complicated by severe pneumonia and heart failure. However, more RCTs with large samples and rigorous design are needed to verify this finding.
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Affiliation(s)
- Wenshen Shao
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Shuangshuang Diao
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lu Zhou
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Lina Cai
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China.
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Akhtar MS, Hassan MQ, Siddiqui A, Alavudeen SS, Afzal O, Altamimi ASA, Rahman SO, Khurana M, Ahsan MJ, Sharma AK, Tabassum F. Levosimendan: mechanistic insight and its diverse future aspects in cardiac care. Acta Cardiol 2022; 78:170-187. [PMID: 36222590 DOI: 10.1080/00015385.2022.2115761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Inotropic agents are generally recommended to use in patients with acute decompensated heart failure (HF) with reduced ejection fraction (HFrEF) concurrent to end-organ dysfunction. However, due to certain pharmacological limitations like developing life threatening arrhythmia and tolerance, cannot be employed as much as needed. Meanwhile, Calcium ion (Ca2+) sensitisers exhibits their inotropic action by increasing the sensitivity of the cardiomyocyte to intracellular Ca2+ ion and have been reported as emerging therapeutic alternative in HF cases. Levosimendan (LEVO) is an inodilator and with its unique pharmacology justifying its use in a wide range of cardiac alterations in HF particularly in undergoing cardiac surgery. It is also reported to be better than classical inotropes in maintaining cardiac mechanical efficacy and reducing congestion in acute HF with hypotension. This review paper was designed to compile various evidence about basic pharmacology and potential clinical aspects of LEVO in cardiac surgery and other HF associated alterations. This will benefit directly to the researcher in initiating research and to fill the gaps in the area of thrust.
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Affiliation(s)
| | - Md Quamrul Hassan
- Department of Pharmacology, SNS College of Pharmacy, Motihari, India
| | - Aisha Siddiqui
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor, Malaysia
| | | | - Obaid Afzal
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Abdulmalik S A Altamimi
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Syed Obaidur Rahman
- Department of Pharmacology, School of Pharmaceutical Education and Research, New Delhi, India
| | - Mallika Khurana
- Department of Pharmacology, School of Pharmaceutical Education and Research, New Delhi, India
| | - Mohamed Jawed Ahsan
- Department of Pharmaceutical Chemistry, Maharishi Arvind College of Pharmacy, Jaipur, India
| | - Arun Kumar Sharma
- Department of Pharmacology, Amity Institute of Pharmacy, Noida, India
| | - Fauzia Tabassum
- Department of Pharmacology, College of Dentistry and Pharmacy, Buraydah, Saudi Arabia
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Levosimendan in paediatric cardiac anaesthesiology. Eur J Anaesthesiol 2022; 39:646-655. [DOI: 10.1097/eja.0000000000001711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Van den Eynde J, Cloet N, Van Lerberghe R, Sá MPB, Vlasselaers D, Toelen J, Verbakel JY, Budts W, Gewillig M, Kutty S, Pottel H, Mekahli D. Strategies to Prevent Acute Kidney Injury after Pediatric Cardiac Surgery: A Network Meta-Analysis. Clin J Am Soc Nephrol 2021; 16:1480-1490. [PMID: 34620647 PMCID: PMC8498996 DOI: 10.2215/cjn.05800421] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/30/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES AKI is a common complication after pediatric cardiac surgery and has been associated with higher morbidity and mortality. We aimed to compare the efficacy of available pharmacologic and nonpharmacologic strategies to prevent AKI after pediatric cardiac surgery. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS PubMed/MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists of relevant articles were searched for randomized controlled trials from inception until August 2020. Random effects traditional pairwise, Bayesian network meta-analyses, and trial sequential analyses were performed. RESULTS Twenty randomized controlled trials including 2339 patients and 11 preventive strategies met the eligibility criteria. No overall significant differences were observed compared with control for corticosteroids, fenoldopam, hydroxyethyl starch, or remote ischemic preconditioning in traditional pairwise meta-analysis. In contrast, trial sequential analysis suggested a 80% relative risk reduction with dexmedetomidine and evidence of <57% relative risk reduction with remote ischemic preconditioning. Nonetheless, the network meta-analysis was unable to demonstrate any significant differences among the examined treatments, including also acetaminophen, aminophylline, levosimendan, milrinone, and normothermic cardiopulmonary bypass. Surface under the cumulative ranking curve probabilities showed that milrinone (76%) was most likely to result in the lowest risk of AKI, followed by dexmedetomidine (70%), levosimendan (70%), aminophylline (59%), normothermic cardiopulmonary bypass (57%), and remote ischemic preconditioning (55%), although all showing important overlap. CONCLUSIONS Current evidence from randomized controlled trials does not support the efficacy of most strategies to prevent AKI in the pediatric population, apart from limited evidence for dexmedetomidine and remote ischemic preconditioning.
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Affiliation(s)
- Jef Van den Eynde
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, Maryland
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Nicolas Cloet
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Michel Pompeu B.O. Sá
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco–PROCAPE, University of Pernambuco–UPE, Recife, Brazil
| | - Dirk Vlasselaers
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jaan Toelen
- Division of Woman and Child, Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jan Y. Verbakel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Werner Budts
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Marc Gewillig
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Shelby Kutty
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, Maryland
| | - Hans Pottel
- Department of Public Health and Primary Care, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Djalila Mekahli
- Department of Pediatric Nephrology, University Hospitals of Leuven, Leuven, Belgium
- PKD Research Group, GPURE, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Zhao L, Tian L, Wang S, Yang W, Lu X, Zhu C. Levosimendan in rats decreases acute kidney injury after cardiopulmonary resuscitation by improving mitochondrial dysfunction. Transl Androl Urol 2021; 10:3010-3020. [PMID: 34430404 PMCID: PMC8350249 DOI: 10.21037/tau-21-443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/23/2021] [Indexed: 01/11/2023] Open
Abstract
Background Acute kidney injury (AKI), the most common complication after cardiac resuscitation, is highly prevalent and harmful. There is increasing evidence that levosimendan can improve cardiac output, increase renal blood flow, and prevent AKI. As a novel calcium sensitizer, levosimendan may exert its protective effect via mitochondria. Methods Rat models of asphyxia-induced cardiac arrest and cardiopulmonary resuscitation (CPR) were set up. Thirty healthy adult male SD rats were randomly divided into CPR group (CPR group, n=10), levosimendan-treated group (levo group, n=10), and sham-operated group (sham group, n=10). Twelve hours after CPR, serum renal function indicators were measured, the kidney injury and mitochondrial morphological changes were observed. Oxygen uptake of the mitochondria, mitochondrial adenosine triphosphate (ATP) and mitochondrial free Ca2+ concentration were measured. Oxidative stress-related indicator levels in rat kidney tissues were further detected to analyze the differences in apoptosis rates among these three groups. Mitochondrial optic atrophy 1 (Opa1), dynamin-related protein 1 (Drp1), and apoptosis-related proteins were detected using Western blotting. Results Compared with the sham group, the CPR group had a significant increase in renal tissue damage. PAS staining and HE stains confirmed that CPR led to renal histopathological damage and destruction of the mitochondrial structure. Levosimendan improved the histopathological and ultrastructural damages of kidneys. Further analysis revealed that mitochondrial ATP content, NADH dehydrogenase, succinate dehydrogenase/cytochrome C oxidase, superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (CSH-Px) decreased. Free Ca2+ concentration and malondialdehyde (MDA) significantly increased (all P<0.05) in the kidney tissues of rats in the CPR group. However, mitochondrial ATP content, NADH dehydrogenase, succinate dehydrogenase/cytochrome C oxidase, SOD, CAT, and CSH-Px increased, whereas free Ca2+ concentration and MDA decreased (all P<0.05) in the levo group. The apoptosis rate increased in the CPR group. There were significantly increased levels of Drp1 protein levels, and significantly decreased Opa1 expression (all P<0.05). However, the levo group showed the opposite effects (all P<0.05). Conclusions Levosimendan can alleviate AKI following CPR, which may be achieved by improving mitochondrial dysfunction and suppressing the mitochondrial apoptosis pathway.
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Affiliation(s)
- Li Zhao
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lei Tian
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shiwei Wang
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weiqiang Yang
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoye Lu
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Changqing Zhu
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Thorlacius EM, Vistnes M, Ojala T, Keski-Nisula J, Molin M, Romlin BS, Synnergren M, Ricksten SE, Wåhlander H, Castellheim A. Levosimendan Versus Milrinone and Release of Myocardial Biomarkers After Pediatric Cardiac Surgery: Post Hoc Analysis of Clinical Trial Data. Pediatr Crit Care Med 2021; 22:e402-e409. [PMID: 33739957 DOI: 10.1097/pcc.0000000000002712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We compared the effect of two inodilators, levosimendan and milrinone, on the plasma levels of myocardial injury biomarkers, that is, high-sensitivity troponin T and heart-type fatty acid binding protein, and on N-terminal prohormone of brain natriuretic peptide as a biomarker of ventricular function. We hypothesized that levosimendan could attenuate the degree of myocardial injury when compared with milrinone. DESIGN A post hoc, nonprespecified exploratory secondary analysis of the Milrinone versus Levosimendan-1 trial (ClinicalTrials.gov Identifier: NCT02232399). SETTING Two pediatric tertiary university hospitals. PATIENTS Infants 1-12 months old, diagnosed with ventricular septal defect, complete atrioventricular septal defect, or Tetralogy of Fallot undergoing corrective surgery with cardiopulmonary bypass. INTERVENTIONS Seventy patients received a loading dose of either levosimendan or milrinone at the start of cardiopulmonary bypass followed by an infusion of the respective drug, which continued for 26 hours. MEASUREMENTS AND MAIN RESULTS Plasma levels of the three cardiac biomarkers were measured prior to the initiation of cardiopulmonary bypass and 2, 6, and 24 hours after weaning from cardiopulmonary bypass. In both groups, the levels of high-sensitivity troponin T and heart-type fatty acid binding protein were highest at 2 hours post cardiopulmonary bypass, whereas the highest level of N-terminal prohormone of brain natriuretic peptide occurred at 24 hours post cardiopulmonary bypass. There was no significant difference in the biomarkers' plasma levels between the study groups over time. Neither was there a significant difference in the postoperative peak plasma levels of the cardiac biomarkers. CONCLUSIONS In this post hoc analysis of the MiLe-1 trial, there was no demonstrable difference in the postoperative cardiac biomarker profile of myocardial injury and ventricular function when comparing infants managed in the perioperative period with levosimendan versus milrinone.
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Affiliation(s)
- Elin M Thorlacius
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Vistnes
- Department of Internal Medicine, Diakonhjemmet Hospital and Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Tiina Ojala
- Department of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Juho Keski-Nisula
- Department of Anesthesia and Intensive Care, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | | | - Birgitta S Romlin
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Synnergren
- Department of Pediatric Thoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Håkan Wåhlander
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Pediatric Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Albert Castellheim
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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Abstract
BACKGROUND Targeted drug development efforts in patients with CHD are needed to standardise care, improve outcomes, and limit adverse events in the post-operative period. To identify major gaps in knowledge that can be addressed by drug development efforts and provide a rationale for current clinical practice, this review evaluates the evidence behind the most common medication classes used in the post-operative care of children with CHD undergoing cardiac surgery with cardiopulmonary bypass. METHODS We systematically searched PubMed and EMBASE from 2000 to 2019 using a controlled vocabulary and keywords related to diuretics, vasoactives, sedatives, analgesics, pulmonary vasodilators, coagulation system medications, antiarrhythmics, steroids, and other endocrine drugs. We included studies of drugs given post-operatively to children with CHD undergoing repair or palliation with cardiopulmonary bypass. RESULTS We identified a total of 127 studies with 51,573 total children across medication classes. Most studies were retrospective cohorts at single centres. There is significant age- and disease-related variability in drug disposition, efficacy, and safety. CONCLUSION In this study, we discovered major gaps in knowledge for each medication class and identified areas for future research. Advances in data collection through electronic health records, novel trial methods, and collaboration can aid drug development efforts in standardising care, improving outcomes, and limiting adverse events in the post-operative period.
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Abstract
Cardiorenal syndrome (CRS) describes a specific acute and chronic clinical picture in which the heart or the kidney are primarily dysfunctioning and secondarily affect each other. CRS is divided into five classes: acute and chronic CRS, acute and chronic renocardiac syndromes, and secondary dysfunction of heart and kidneys. This article specifically details the classification and the epidemiology, some risk factors, and the pathophysiology of CRS. Some emerging aspects of CRS are also discussed, such as CRS in patients with end-stage heart failure, with mechanical ventricular assistance, and after heart transplantation. Finally, some aspects of pediatric CRS are detailed.
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Affiliation(s)
- Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, P.zza S.Onofrio 4, Rome 00165, Italy; Department of Health Science, University of Florence, Florence, Italy.
| | - Stefano Romagnoli
- Department of Health Science, University of Florence, Florence, Italy; Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla, 3, Florence 50139, Italy. https://twitter.com/StefanoRomagno9
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy; Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Via Rodolfi 37, Vicenza 36100, Italy. https://twitter.com/croncoIRRIV
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An evidence-based review of the use of vasoactive and inotropic medications in post-operative paediatric patients after cardiac surgery with cardiopulmonary bypass from 2000 to 2020. Cardiol Young 2020; 30:1757-1771. [PMID: 33213604 DOI: 10.1017/s1047951120004151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Infants with moderate-to-severe CHD frequently undergo cardiopulmonary bypass surgery in childhood. Morbidity and mortality are highest in those who develop post-operative low cardiac output syndrome. Vasoactive and inotropic medications are mainstays of treatment for these children, despite limited evidence supporting their use. METHODS To help inform clinical practice, as well as the conduct of future trials, we performed a systematic review of existing literature on inotropes and vasoactives in children after cardiac surgery using the PubMed and EMBASE databases. We included studies from 2000 to 2020, and the patient population was defined as birth - 18 years of age. Two reviewers independently reviewed studies to determine final eligibility. RESULTS The final analysis included 37 papers. Collectively, selected studies reported on 12 different vasoactive and inotropic medications in 2856 children. Overall evidence supporting the use of these drugs in children after cardiopulmonary bypass was limited. The majority of studies were small with 30/37 (81%) enrolling less than 100 patients, 29/37 (78%) were not randomised, and safety and efficacy endpoints differed widely, limiting the ability to combine data for meta-analyses. CONCLUSION Vasoactive and inotropic support remain critical parts of post-operative care for children after cardiopulmonary bypass surgery. There is a paucity of data for the selection and dosing of vasoactives and inotropes for these patients. Despite the knowledge gaps that remain, numerous recent innovations create opportunities to rethink the conduct of clinical trials in this high-risk population.
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Thorlacius EM, Wåhlander H, Ojala T, Ylänen K, Keski-Nisula J, Synnergren M, Romlin BS, Ricksten SE, Castellheim A. Levosimendan Versus Milrinone for Inotropic Support in Pediatric Cardiac Surgery: Results From a Randomized Trial. J Cardiothorac Vasc Anesth 2020; 34:2072-2080. [DOI: 10.1053/j.jvca.2020.02.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 12/23/2022]
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Staudt GE, Eagle SS. A Tale of 2 Inodilators: Much Ado About Nothing? J Cardiothorac Vasc Anesth 2020; 34:2081-2082. [PMID: 32439191 DOI: 10.1053/j.jvca.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/05/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Genevieve E Staudt
- Department of Anesthesiology, Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
| | - Susan S Eagle
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
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Another Outcome Lost to the Benefits of Levosimendan? Pediatr Crit Care Med 2019; 20:992-994. [PMID: 31580276 DOI: 10.1097/pcc.0000000000002019] [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]
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