Postoperative Cerebral Oxygen Saturation in Children After Congenital Cardiac Surgery and Long-Term Total Intelligence Quotient: A Prospective Observational Study

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.

P4790Haematuria is not elevated in AF patients treated with NOACs versus VKAs: GARFIELD-AF study

Background

Haematuria in atrial fibrillation (AF) patients taking oral anticoagulants (OACs) is usually viewed as less serious than intracranial and gastrointestinal bleeding. It is speculated that haematuria may result from renal excretion of active new oral anticoagulants (NOACs) causing a direct anticoagulating effect in the urinary tract. Vitamin K antagonists (VKAs) such as warfarin, on the other hand, undergo hepatic metabolism and may pose lower risk of haematuria. This large registry study investigated whether NOACs more likely cause haematuria compared with VKAs.

Purpose

To assess whether there is any difference in the incidence rate of haematuria in AF patients taking NOACs versus VKAs using data from the GARFIELD-AF registry.

Methods

GARFIELD-AF is an international prospective registry of nonvalvular AF patients with at least one additional risk factor for stroke, followed for at least 2 years. Macroscopic haematuria was identified by local investigators. Event rates were estimated by Poisson model. Adjusted hazard ratio (HR) for haematuria between treatment groups was calculated using overlap-weighted Cox model including a range of patient demographics and clinical parameters as variables. Only the first haematuria occurrence was considered. Patients who were not treated with either VKAs or NOACs were excluded.

Results

Among a registry population of 34,926 patients 24,079 were anticoagulated and 24,061 had available follow-up data. Baseline characteristics were evenly balanced between the VKAs and NOACs subgroups, except a somewhat higher proportion of VKA patients than NOAC patients received concomitant antiplatelet therapy. Rate of haematuria was similar between the two groups: VKAs, 115/12,307 cases (0.9% over study period; 0.55 [95% CI, 0.46–0.65] per 100 patient-years); NOACs, 119/11,754 cases (1.0% over study period; 0.49 [95% CI, 0.41–0.59] per 100 patient-years). Over 2 years cumulatively, adjusted HR for haematuria in NOAC group versus VKA was 0.85 (95% CI, 0.63–1.15; p=0.29). Most haematuria cases (approximately 94%) were minor or clinically relevant non-major bleeds, occurring at a similar rate in both subgroups. Major bleeds were very rare. No intervention was necessary in two thirds haematuria cases (65.2%); surgical procedures were performed in only 8.3%. No haematuria-related deaths were observed.

Incidence of haematuria

Conclusions

The incidence and severity of haematuria were not increased in AF patients taking NOACs versus VKAs. Haematuria may occur in approximately one in 100 AF patients on long-term OACs therapy and is usually non-serious.

Acknowledgement/Funding

The GARFIELD-AF registry is funded by an unrestricted research grant from Bayer AG.

Non-Thyroidal Illness Syndrome in Critically Ill Children: Prognostic Value and Impact of Nutritional Management

INTRODUCTION

Non-thyroidal illness (NTI), which occurs with fasting and in response to illness, is characterized by thyroid hormone inactivation with low triiodothyronine (T3) and high reverse T3 (rT3), followed by suppressed thyrotropin (TSH). Withholding supplemental parenteral nutrition early in pediatric critical illness (late-PN), thus accepting low/no macronutrient intake up to day 8 in the pediatric intensive care unit (PICU), accelerated recovery compared to initiating supplemental parenteral nutrition early (early-PN). Whether NTI is harmful or beneficial in pediatric critical illness and how it is affected by a macronutrient deficit remains unclear. This study investigated the prognostic value of NTI, the impact of late-PN on NTI, and whether such impact explains or counteracts the outcome benefit of late-PN in critically ill children.

METHODS

This preplanned secondary analysis of the Early versus Late Parenteral Nutrition in the Pediatric Intensive Care Unit randomized controlled trial quantified serum TSH, total thyroxine (T4), T3, and rT3 concentrations in 982 patients upon PICU admission versus 64 matched healthy children and in 772 propensity score-matched early-PN and late-PN patients upon admission and at day 3 or last PICU day for shorter PICU stay. Associations between thyroid hormone concentrations upon admission and outcome, as well as impact of late-PN on NTI in relation with outcome, were assessed with univariable analyses and multivariable logistic regression, linear regression, or Cox proportional hazard analysis, adjusted for baseline risk factors.

RESULTS

Upon PICU admission, critically ill children revealed lower TSH, T4, T3, and T3/rT3 and higher rT3 than healthy children (p < 0.0001). A more pronounced NTI upon admission, with low T4, T3, and T3/rT3 and high rT3 was associated with higher mortality and morbidity. Late-PN further reduced T4, T3, and T3/rT3 and increased rT3 (p ≤ 0.001). Statistically, the further lowering of T4 by late-PN reduced the outcome benefit (p < 0.0001), whereas the further lowering of T3/rT3 explained part of the outcome benefit of late-PN (p ≤ 0.004). This effect was greater for infants than for older children.

CONCLUSION

In critically ill children, the peripheral inactivation of thyroid hormone, characterized by a decrease in T3/rT3, which is further accentuated by low/no macronutrient intake, appears beneficial. In contrast, the central component of NTI attributable to suppressed TSH, evidenced by the decrease in T4, seems to be a harmful response to critical illness. Whether treating the central component with TSH releasing hormone infusion in the PICU is beneficial requires further investigation.

Phthalate and alternative plasticizers in indwelling medical devices in pediatric intensive care units

The present study aimed to identify plasticizers present in indwelling plastic medical devices commonly used in the pediatric intensive care unit (PICU). We have analyzed a wide range of medical devices (n = 97) daily used in the PICUs of two academic hospitals in Belgium and the Netherlands. Identified compounds varied between the samples. Most of the indwelling medical devices and essential accessories were found to actively leach phthalates and alternative plasticizers. Results indicated that DEHP was predominantly present as plasticizer (60 of 97 samples), followed by bis(2-ethylhexyl) adipate (DEHA, 32 of 97), bis(2-ethylhexyl) terephthalate (DEHT, 24 of 97), tris(2-ethylhexyl) trimellitate (TOTM, 20 of 97), and tributyl-O-acetyl citrate (ATBC, 10 of 97). Other plasticizers, such as di-isononyl-cyclohexane-1,2-dicarboxylate (DINCH, 2 of 97), di-isononyl phthalate (DiNP, 4 of 97), di(2-propylheptyl) phthalate (DPHP, 4 of 97) and di-isodecyl phthalate (DiDP, 2 of 97) were detected in < 5% of the investigated samples. Several devices contained multiple plasticizers, e.g. devices containing TOTM contained also DEHP and DEHT. Our data indicate that PICU patients are exposed to a wide range of plasticizers, including the controversial DEHP. Future studies should investigate the exposure to APs in children staying in the PICU and the possible health effects thereof.

Long-term developmental effects of withholding parenteral nutrition for 1 week in the paediatric intensive care unit: a 2-year follow-up of the PEPaNIC international, randomised, controlled trial

BACKGROUND

The paediatric early versus late parenteral nutrition in critical illness (PEPaNIC) multicentre, randomised, controlled trial showed that, compared with early parenteral nutrition, withholding supplemental parenteral nutrition for 1 week in the paediatric intensive care unit (PICU; late parenteral nutrition) reduced infections and accelerated recovery from critical illness in children. We aimed to investigate the long-term impact on physical and neurocognitive development of early versus late parenteral nutrition.

METHODS

In this preplanned 2-year follow-up study, all patients included in the PEPaNIC trial (which was done in University Hospitals Leuven, Belgium; Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands; and Stollery Children's Hospital, Edmonton, AB, Canada) were approached for possible assessment of physical and neurocognitive development compared with healthy children who were matched for age and sex, and who had never been admitted to a neonatal ICU or a PICU. Assessed outcomes comprised anthropometric data; health status; parent-reported or caregiver-reported executive functions and emotional and behavioural problems; and tests for intelligence, visual-motor integration, alertness, motor coordination, inhibitory control, cognitive flexibility, and memory. To address partial responses among the children tested, we did multiple data imputation by chained equations before univariable and multivariable linear and logistic regression analyses adjusted for risk factors. This trial is registered with ClinicalTrials.gov, number NCT01536275.

FINDINGS

At the 2-year follow-up, 60 (8%) of 717 children who received late parenteral nutrition and 63 (9%) of 723 children who received early parenteral nutrition had died (p=0·81). 68 (9%) of 717 children who received late and 91 (13%) of 723 children who received early parenteral nutrition were too disabled for neurocognitive assessment (p=0·059), and 786 patients (395 assigned to late and 391 assigned to early parenteral nutrition) consented for testing. 786 patients and 405 healthy control children underwent long-term outcome testing between Aug 4, 2014, and Jan 19, 2018, and were included in the imputation model for subsequent multivariable analyses. Late parenteral nutrition did not adversely affect anthropometric data, health status, or neurological functioning, and improved parent-reported or caregiver-reported executive functioning (late vs early parenteral nutrition β estimate -2·258, 95% CI -4·012 to -0·504; p=0·011), more specifically inhibition (-3·422, -5·171 to -1·673; p=0·0001), working memory (-2·016, -3·761 to -0·270; p=0·023), and meta-cognition (-1·957, -3·694 to -0·220; p=0·027). Externalising behavioural problems (β estimate -1·715, 95% CI -3·325 to -0·106; p=0·036) and visual-motor integration (0·468, 0·087 to 0·850; p=0·016) were also improved in the late parenteral nutrition group compared with the early parenteral nutrition group. After Bonferroni correction for multiple comparisons, the effect on inhibitory control remained significant (p=0·0001).

INTERPRETATION

Withholding early parenteral nutrition for 1 week in the PICU did not negatively affect survival, anthropometrics, health status, and neurocognitive development, and improved inhibitory control 2 years after PICU admission.

FUNDING

European Research Council Advanced Grant, Methusalem programme provided by the Flemish Government, Flemish Agency for Innovation by Science and Technology (IWT), Research Foundation Flanders (FWO), Sophia Children's Hospital Foundation (SSWO), Stichting Agis Zorginnovatie, Erasmus Trustfonds, and European Society for Parenteral and Enteral Nutrition (ESPEN) research grant.

Cost-effectiveness study of early versus late parenteral nutrition in critically ill children (PEPaNIC): preplanned secondary analysis of a multicentre randomised controlled trial

Background

The multicentre randomised controlled PEPaNIC trial showed that withholding parenteral nutrition (PN) during the first week of critical illness in children was clinically superior to providing early PN. This study describes the cost-effectiveness of this new nutritional strategy.

Methods

Direct medical costs were calculated with use of a micro-costing approach. We compared the costs of late versus early initiation of PN (n = 673 versus n = 670 patients) in the Belgian and Dutch study populations from a hospital perspective, using Student’s t test with bootstrapping. Main cost drivers were identified and the impact of new infections on the total costs was assessed.

Results

Mean direct medical costs for patients receiving late PN (€26.680, IQR €10.090–28.830 per patient) were 21% lower (-€7.180, p = 0.007) than for patients receiving early PN (€33.860, IQR €11.080–34.720). Since late PN was more effective and less costly, this strategy was superior to early PN. The lower costs for PN only contributed 2.1% to the total cost reduction. The main cost driver was intensive care hospitalisation costs (-€4.120, p = 0.003). The patients who acquired a new infection (14%) were responsible for 41% of the total costs. Sensitivity analyses confirmed consistency across both healthcare systems.

Conclusions

Late initiation of PN decreased the direct medical costs for hospitalisation in critically ill children, beyond the expected lower costs for withholding PN. Avoiding new infections by late initiation of PN yielded a large cost reduction. Hence, late initiation of PN was superior to early initiation of PN largely via its effect on new infections.

Trial registration

ClinicalTrials.gov, NCT01536275. Registered on 16 February 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1936-2) contains supplementary material, which is available to authorized users.

Impact of withholding early parenteral nutrition completing enteral nutrition in pediatric critically ill patients (PEPaNIC trial): study protocol for a randomized controlled trial

Background

The state-of-the-art nutrition used for critically ill children is based essentially on expert opinion and extrapolations from adult studies or on studies in non-critically ill children. In critically ill adults, withholding parenteral nutrition (PN) during the first week in ICU improved outcome, as compared with early supplementation of insufficient enteral nutrition (EN) with PN. We hypothesized that withholding PN in children early during critical illness reduces the incidence of new infections and accelerates recovery.

Methods/Design

The Pediatric Early versus Late Parenteral Nutrition in Intensive Care Unit (PEPaNIC) study is an investigator-initiated, international, multicenter, randomized controlled trial (RCT) in three tertiary referral pediatric intensive care units (PICUs) in three countries on two continents. This study compares early versus late initiation of PN when EN fails to reach preset caloric targets in critically ill children. In the early-PN (control, standard of care) group, PN comprising glucose, lipids and amino acids is administered within the first days to reach the caloric target. In the late-PN (intervention) group, PN completing EN is only initiated beyond PICU-day 7, when EN fails. For both study groups, an early EN protocol is applied and micronutrients are administered intravenously. The primary assessor-blinded outcome measures are the incidence of new infections during PICU-stay and the duration of intensive care dependency. The sample size (n = 1,440, 720 per arm) was determined in order to detect a 5% absolute reduction in PICU infections, with at least 80% 1-tailed power (70% 2-tailed) and an alpha error rate of 5%. Based on the actual incidence of new PICU infections in the control group, the required sample size was confirmed at the time of an a priori- planned interim-analysis focusing on the incidence of new infections in the control group only.

Discussion

Clinical evidence in favor of early administration of PN in critically ill children is currently lacking, despite potential benefit but also known side effects. This large international RCT will help physicians to gain more insight in the clinical effects of omitting PN during the first week of critical illness in children.

Trial registration

ClinicalTrials.gov: NCT01536275 on 16 February 2012.

Lower incidence of post-dural puncture headache with spinal catheterization after accidental dural puncture in obstetric patients

BACKGROUND

Accidental dural puncture (ADP) and post-dural puncture headache (PDPH) are important complications of obstetric regional anesthesia. Inserting the catheter intrathecally after ADP to prevent PDPH has gained popularity. Nonetheless, data on the effect of an intrathecal catheter on PDPH and epidural blood patch (EBP) rates are mixed. Our primary objective was to examine if spinal catheterization reduces the incidence of PDPH after ADP in obstetric patients.

METHODS

Anesthetic records of 29,749 regional blocks performed between January 1997 and July 2013 were analyzed retrospectively. In all blocks containing an epidural component, 18-gauge epidural needles were used. All patients who experienced a witnessed ADP or PDPH without ADP were identified. Data from patients with or without a prolonged spinal catheter were compared.

RESULTS

There were 128 events of witnessed ADP (0.43%). Following known ADP, 39 women had an epidural catheter placed at a different level and 89 had an intrathecal catheter (20-gauge) for at least 24 h. Sixty-one patients developed PDPH after observed ADP (48%). Prolonged intrathecal catheter placement significantly reduced the incidence of PDPH after ADP to 42% compared with 62% in those who have the catheter re-sited epidurally [odds ratio = 2.3 (95% confidence interval 1.04-4.86); P = 0.04].

CONCLUSIONS

The incidence of ADP, PDPH and blood patching is similar with previously published studies. After witnessed ADP, inserting the epidural catheter intrathecally significantly reduced the incidence of PDPH.

Post-cesarean section analgesia

Cesarean section patients have compelling reasons to achieve optimal postoperative pain relief, because they are expected to recover expeditiously and to care for their newborns within a few hours following surgery. Consequently, it is necessary that pain relief is safe and effective, that it does not interfere with the mother's ability to care for her infant, and that it results in no adverse neonatal effects in breast-feeding women. However, although research in this field is increasing, there is no 'gold standard' for post-caesarean pain management. Most methods rely on opioids, supplemented with non-opioid analgesics, nerve blocks or other adjunctive techniques. The aim of this manuscript is to evaluate and compare through literature review commonly used opioid- and non-opioid-based methods, when incorporated into a multimodal approach to post-caesarean pain management. Areas of promising research are also discussed.

A multi-stage sampling strategy for the delineation of soil pollution in a contaminated brownfield

A multi-stage sampling strategy, based on sequential Gaussian simulation, was presented to optimize the step-wise selection of a small numbers of additional samples to delineate soil pollution. This strategy was applied to a Belgian brownfield of 5.2 ha polluted with lead (Pb). Starting from an initial number of 240 samples in stage 1, additional samples were added, 25 per stage, and the reduction of the uncertainty in the Pb delineation was monitored. Twenty stages were used. Already in stage 6 a local optimum was found based on the median conditional coefficient of variation. An independent validation confirmed that this index was to be preferred over the median conditional variance. So for the brownfield considered our procedure indicated that 365 selected samples would have been sufficient, representing a gain of 70.7% in sampling effort compared to current practice which resulted in a sampling effort of 1245 samples.

Serological survey of Toxoplasma gondii, feline immunodeficiency virus and feline leukaemia virus in urban stray cats in Belgium

Three hundred and forty-six serum samples taken between 1998 and 2000 from urban stray cats in the city of Ghent were tested for antibodies to Toxoplasma gondii and feline immunodeficiency virus (FIV), and antigens of feline leukemia virus (FeLV). Of these 346 samples, 243 (70.2 per cent) were seropositive for Tgondii. Thirty-nine cats (11.3 per cent) had antibodies against FIV and 13 (3.8 per cent) had circulating antigens of FeLV. Fewer of the female cats had FIV and heavier cats had a higher seroprevalence of FIV. Exact logistic regression showed that cats that were infected with FIV were more likely to be infected with T gondii (P = 0.04), and the cats with FIV had a higher titre of Tgondii antibodies than FIV-negative animals. However, FeLV was not associated with either T gondii or FIV.

Comparison of the reactivity of oxaliplatin, pt(diaminocyclohexane)Cl2 and pt(diaminocyclohexane1)(OH2)2(2+) with guanosine and L-methionine

The initial rates of reactivity of oxaliplatin, its metabolites Pt(dach)Cl2 and Pt(dach)(OH2)2(2+) with guanosine and L-met in water, NaCl and phosphate were compared. Versus guanosine, the most reactive molecule was Pt(dach)(OH2)2(2+), about 40 fold that of oxaliplatin, the least reactive was Pt(dach)Cl2, Versus L-met, Pt(dach)(OH2)2(2+), was also the most reactive species but only about 2 fold more reactive than Pt(dach)Cl2 and oxaliplatin. Pt(dach)(OH2)2(2+) was approximately 3 fold less reactive versus methionine than guanosine whereas oxaliplatin and Pt(dach)Cl2 were about seven fold more reactive versus methionine than guanosine. Thus, the three platinum compounds oxaliplatin, Pt(dach)Cl2 and Pt(dach)(OH2)2(2+) react with L-met but only the Pt(dach)(OH2)2(2+) has a high reactivity with guanosine. Oxaliplatin, which is stable in water, has to be transformed in the presence of chloride in chloro-derivatives which are aquated to become active particularly versus guanosine. These data demonstrate that oxaliplatin has similarities with cisplatin in terms of chloride versus water coordination and in terms of dependence on chloride concentration for transformations.

Successful control of refractory and life-threatening autoimmune hemolytic anemia with intravenous immunoglobulins in a man with the primary antiphospholipid syndrome

A 58-year old man with a history of hypothyroidism and primary antiphospholipid syndrome (with recurrent thromboembolic disease and therapy-refractory autoimmune thrombocytopenic purpura) presented with a life-threatening crisis of warm autoimmune hemolytic anemia (AIHA) while under chronic low-dose steroid therapy. The exacerbation was eventually controlled with a 5-day course of intravenous immunoglobulin (IVIG, Sandoglobulin) (400 mg/kg per day) but hemolysis rapidly recurred, despite therapy with steroids, azathioprine, and cyclosporin, necessitating a second course of IVIG. Control of packed cell transfusion needs for about 7 months was achieved by weekly administration of IVIG (800 mg/kg), although there is no direct evidence that IVIG therapy reduced the production of anticardiolipin or RBC antibodies. Three months after discontinuation of IVIG and change to maintenance with intermediate-dose corticosteroids plus cyclosporin A, the patient succumbed to duodenal perforation with peritonitis and invasive pulmonary aspergillosis. The case illustrates that IVIG therapy may be helpful in selected life-threatening and refractory cases of AIHA. It also sadly illustrates the long-term toxicity of standardly used therapeutics in refractory AIHA.