Impact of surfactant when utilized during pediatric cardiac surgery admissions: analysis of a nationwide database

OBJECTIVE

Surfactant has been routinely used in the neonatal population, particularly in the setting of prematurity and neonatal respiratory distress syndrome. Current evidence, however, does not delineate the effect of surfactant use in neonates and older children during cardiac surgery admissions. This study aimed to characterize the impact of surfactant on pediatric cardiac surgery admissions.

METHODS

Admissions of those under 18 years of age with cardiac surgery were identified from the Pediatric Health Information System (PHIS) database between 2004 and 2015, using ICD-9 procedure codes. Univariate analyses were conducted to compare admission characteristics between those that did and not utilize surfactant. Variables shown to be significant were then entered as independent variables into the regression analyses. Surfactant was entered into each model as an independent variable.

RESULTS

A total of 81,313 admissions met the inclusion criteria. Of these, 109 (0.1%) had surfactant utilized. Univariate analyses identified several differences between admissions with and without surfactant use and demonstrated significantly increased mortality in the surfactant group (38.5% versus 4.6%, p < .01). Regression analyses demonstrated that surfactant was independently associated with increased mortality (odds ratio 6.0, 95% confidence interval 3.9-9.3, p < .01). Univariate analysis in only surfactant admissions demonstrated the following to be associated with inpatient mortality: younger age, prematurity, Ebstein anomaly, and hypoplastic left heart syndrome.

CONCLUSIONS

Surfactant administration during pediatric cardiac surgery admissions is independently associated with a sixfold increase in inpatient mortality. It is likely that these findings are mediated by augmentation of the decrease in pulmonary vascular resistance and a subsequent decrease in systemic blood flow in the setting of parallel circulation. Surfactant should be administered with special consideration in neonates with cardiac disease and may be best avoided in those with parallel circulation.

Effect of low-dose exogenous surfactant on infants with acute respiratory distress syndrome after cardiac surgery: a retrospective analysis

BACKGROUND

Acute respiratory distress syndrome (ARDS) in infants undergoing cardiac surgery is associated with significant mortality and prolonged ventilation; surfactant administration may be a useful therapy. The purpose of this study is to evaluate the effect of low-dose exogenous surfactant therapy on infants suffering ARDS after cardiac surgery.

METHODS

We conducted a case-control study of infants diagnosed with moderate-to-severe ARDS (PaO₂/FiO₂ < 150) after cardiac surgery. A case was defined as a patient that received surfactant and standard therapy, while a control was defined as a patient that underwent standard therapy. The primary endpoint was the improvement in oxygenation index (OI) after 24-h of surfactant treatment; and secondary endpoints were the ventilator time and PICU time.

RESULTS

Twenty-two infants treated with surfactant were matched with 22 controls. Early low-dose (20 mg/kg) surfactant treatment was associated with improved outcomes. After surfactant administration for 24-h, the surfactant group was much better compared with the control group at the 24-h in OI (difference in average change from baseline, - 6.7 [95% CI, - 9.3 to - 4.1]) (P < 0.01) and ventilation index (VI, mean difference, - 11.9 [95% CI, - 18.1 to - 5.7]) (P < 0.01). Ventilation time and PICU time were significantly shorter in the surfactant group compared with the control group (133.6 h ± 27.2 vs 218.4 h ± 28.7, P < 0.01; 10.7d ± 5.1 vs 17.5d ± 6.8, P < 0.01). Infants in the surfactant group under 3 months benefit more from OI and VI than the infants over 3 months in a preliminary exploratory analysis.

CONCLUSIONS

In infants with moderate-to-severe ARDS after cardiac surgery, early low-dose exogenous surfactant treatment could prominently improve oxygenation and reduce mechanical ventilation time and PICU time. Infants younger than 3 months may get more benefit of oxygenation than the older ones. Randomized controlled trials are needed to explore the effect of surfactant to ARDS of cardiac surgical infants.