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.
Das Noonan-Syndrom (NS) gehört zu einer Gruppe monogen bedingter Entwicklungsstörungen, denen als gemeinsame pathogenetische Basis eine Dysregulation des RAS/MAPK-Signalwegs zugrunde liegt; zusammen ...werden sie daher auch als „RASopathien“ bezeichnet. Die verschiedenen Formen der RASopathien, welche durch Mutationen in unterschiedlichen Komponenten oder Modulatoren des Signalwegs hervorgerufen werden, unterscheiden sich in der Ausprägung typischer Symptome. Hierzu gehören auffällige Gesichtszüge, Kleinwuchs, kognitive Einschränkungen, ein erhöhtes Tumorrisiko und kardiale Anomalien. Davon ist insbesondere die bei etwa 30 % der Patienten mit NS vorkommende hypertrophe Kardiomyopathie mit einer hohen Morbidität und auch Mortalität vergesellschaftet. Aktuell sind hierfür noch keine Kausaltherapien verfügbar, da zugrunde liegende Pathomechanismen dieser Erkrankungen noch nicht ausreichend verstanden werden. Beispielhaft für den aktuellen Stand der Wissenschaft in der Grundlagenforschung wird die induziert pluripotente Stammzellen (iPS) Zell-basierte Krankheitsmodellierung des kardialen Phänotyps einer Patientin mit RIT1-assoziiertem NS angeführt. Erste vielversprechende Daten, die auf eine zukünftige Kausaltherapie mittels Mitogen-aktivierter-Protein-Kinase-Kinase(MEK)-Inhibition hinweisen, konnten bereits gesammelt werden.
Zusammenfassung
Das Noonan-Syndrom (NS) gehört zu einer Gruppe monogen bedingter Entwicklungsstörungen, denen als gemeinsame pathogenetische Basis eine Dysregulation des RAS/MAPK-Signalwegs zugrunde ...liegt; zusammen werden sie daher auch als „RASopathien“ bezeichnet. Die verschiedenen Formen der RASopathien, welche durch Mutationen in unterschiedlichen Komponenten oder Modulatoren des Signalwegs hervorgerufen werden, unterscheiden sich in der Ausprägung typischer Symptome. Hierzu gehören auffällige Gesichtszüge, Kleinwuchs, kognitive Einschränkungen, ein erhöhtes Tumorrisiko und kardiale Anomalien. Davon ist insbesondere die bei etwa 30 % der Patienten mit NS vorkommende hypertrophe Kardiomyopathie mit einer hohen Morbidität und auch Mortalität vergesellschaftet. Aktuell sind hierfür noch keine Kausaltherapien verfügbar, da zugrunde liegende Pathomechanismen dieser Erkrankungen noch nicht ausreichend verstanden werden. Beispielhaft für den aktuellen Stand der Wissenschaft in der Grundlagenforschung wird die induziert pluripotente Stammzellen (iPS) Zell-basierte Krankheitsmodellierung des kardialen Phänotyps einer Patientin mit RIT1-assoziiertem NS angeführt. Erste vielversprechende Daten, die auf eine zukünftige Kausaltherapie mittels Mitogen-aktivierter-Protein-Kinase-Kinase(MEK)-Inhibition hinweisen, konnten bereits gesammelt werden.
We report a case of a 3-week-old infant who presented a heart murmur and low oxygen saturation. An echocardiography was performed and presented a common arterial trunk type B4 with an interrupted ...aortic arch and intact ventricular septum. We describe the surgical management and short-term follow-up.
Optimizing oxygen delivery to the brain is one of the main goals in children with congenital heart defects after surgery. It has been shown that cerebral oxygen saturation (cSO2) is depressed within ...the first day after neonatal cardiopulmonary bypass surgery. However, peri-operative cerebral oxygen metabolism has not yet been assessed in previous studies. The aim of this study was to describe the peri-operative changes in cerebral oxygen metabolism in neonates with congenital heart defects following cardiopulmonary bypass surgery. Prospective observational cohort study. PICU of a tertiary referral center. Fourteen neonates with hypoplastic left heart syndrome (HLHS) undergoing Norwood procedure and 14 neonates with transposition of great arteries (TGA) undergoing arterial switch operation (ASO) were enrolled. Pediatric heart surgery. We measured non-invasively regional cSO2 and microperfusion (rcFlow) using tissue spectrometry and laser Doppler flowmetry before and after surgery. Cerebral fractional tissue oxygen extraction (cFTOE), the arterio–cerebral difference in oxygen content (acDO2) and approximated cerebral metabolic rate of oxygen (aCMRO2) were calculated. According to the postsurgical hemodynamics, arterial saturation (aSO2) normalized immediately after surgery in the TGA group, whereas HLHS patients still were cyanotic. cSO2 significantly increased in TGA group over 48 h after ASO (
p
= 0.004) and was significantly higher compared to HLHS group after Norwood procedure. cFTOE as a risk marker for brain injury was elevated before surgery (TGA group 0.37 ± 0.10, HLHS group 0.42 ± 0.12) and showed a slight decrease after ASO (
p
= 0.35) but significantly decreased in patients after Norwood procedure (
p
= 0.02). Preo-peratively, acDO2 was significantly higher in patients with HLHS compared to patients with TGA (7.7 ± 2.5 vs. 5.2 ± 1.6 ml/dl,
p
= 0.005), but normalized in the posto-perative course. Before surgery, the aCMRO2 was slightly higher in the HLHS group (5.1 ± 1.5 vs. 3.9 ± 2.5 AU,
p
= 0.14), but significantly decreased after Norwood procedure (− 1.6 AU,
p
= 0.009). There was no difference in rcFlow between both groups and between the points in time prior and after surgery. Neonates undergoing cardiac surgery suffer from peri-operative changes in hemodynamics and cerebral hypoxemic stress. The cerebral oxygen metabolism seems to be more affected in cyanotic children with functionally univentricular hearts compared to post-operative acyanotic patients. Additional stress factors must be avoided to achieve the best possible neurological outcome.
The electrical excitation of the heart causes weak magnetic fields that can be recorded without skin contact over the body surface by magnetocardiography (MCG). Menendez et al investigated the ...feasibility of MCG in a clinical work routine to detect and analyze fetal rhythm disorders.
We aimed to reduce blood loss in the pediatric critical care unit (PICU) due to blood sampling in neonates and infants. Therefore, an educational program for our staff was established and evaluated.
...Patients in a PICU of a tertiary referral center aged 0-12 months who underwent surgery of congenital heart disease on cardiopulmonary bypass were enrolled and divided into a pre- and a post-implementation group. We assessed frequency and types of postoperative blood samples, required blood volume, and amount of blood transfusions in the PICU within 5 days after cardiac surgery.
Populations were similar prior and after the implementation. Blood drawn for blood gas analysis (0,52 ml±0,16 vs. 0,38 ml±0,12, p<0,001) and for complete blood sampling (2,62 ml±0,32 vs. 2,11 ml±0,35, p<0,001) could be successfully reduced after implementation of our blood-saving program. The daily diagnostic blood loss per patient was significantly reduced by approximately 35% (1,7 ml/kg/d±1,0 vs. 1,1 ml/kg/d±0,7, p=0,008).
Our quality improvement program is feasible and effective to significantly reduce the blood loss due to blood sampling. Although the incidence of red blood cell transfusions was not significantly reduced, it is certainly beneficial to try to reduce diagnostic blood loss, especially in children with complex diseases requiring long-term intensive care treatment.
We could demonstrate that it is possible to significantly reduce the blood loss due to blood sampling with a simple educational program for PICU staff.
Unser Ziel war es, den Blutverlust durch Blutabnahmen auf der pädiatrischen Intensivstation bei Neugeborenen und Säuglingen zu reduzieren. Deshalb wurde ein Schulungsprogramm für unsere Mitarbeiter etabliert und ausgewertet.
Patienten unserer pädiatrischen Intensivstation im Alter von 0-12 Monaten nach einer Operation eines angeborenen Herzfehlers mit Herz-Lungen-Maschine, wurden eingeschlossen und in eine Gruppe vor und nach der Implementierung des Schulungsprogramms zugeteilt. Wir haben die Häufigkeit und Art der postoperativen Blutproben, das benötigte Blutvolumen und die Menge der Bluttransfusionen auf der Intensivstation innerhalb von 5 Tagen nach der Herzoperation ausgewertet.
Die Patientencharakteristik beider Gruppen zeigte keine relevanten Unterschiede. Blut, das für Blutgasanalysen (0,52 ml±0,16 vs. 0,38 ml±0,12, p<0,001) und für vollständige Blutentnahmen (2,62 ml±0,32 vs. 2,11 ml±0,35, p<0,001) entnommen wurde, konnte nach Umsetzung unseres Blutsparprogramms erfolgreich reduziert werden. Der tägliche diagnostische Blutverlust pro Patienten wurde signifikant um ca. 35% reduziert (1,7 ml/kg/d±1,0 vs. 1,1 ml/kg/d±0,7, p=0,008).
Unser Schulungsprogramm für Mitarbeiter ist einfach umzusetzen und effektiv, den Blutverlust durch Blutentnahmen deutlich zu reduzieren. Obwohl die Inzidenz von Bluttransfusionen nicht signifikant reduziert wurde, ist es sicherlich erstrebenswert, den diagnostischen Blutverlust insbesondere bei Kindern mit komplexen Krankheiten, die eine langfristige Intensivbehandlung erfordern, zu reduzieren.
Wir konnten zeigen, dass es möglich ist, den Blutverlust durch Blutentnahme mit einem einfachen Schulungsprogramm für Mitarbeiter auf der Intensivstation deutlich zu reduzieren.
Objectives
To describe the efficacy and safety of stent‐retriever thrombectomy in infants with thrombosis of the superior vena cava (SVC) and innominate vein.
Background
Thrombosis of the SVC and of ...the innominate vein is a potentially life threatening complication in infants during intensive care treatment following major surgical procedures. To avoid reoperations, we evaluated interventional revascularization by stent‐retriever thrombectomy.
Methods
From 2015 to 2017, five infants were diagnosed with acute thrombosis of the SVC and innominate vein following major cardiac or pediatric surgery. Using a femoral venous access and 4 or 5 French guiding catheters stent‐retriever systems (4/20 mm or 6/30 mm) were placed into the thrombus and retrieved under suction. We aimed to revascularize not only the SVC but also the innominate, jugular, and subclavian veins.
Results
Following repeated stent retrieving manoeuvers, we were able to reestablish flow in the major veins of all patients. Due to significant residual thrombotic material, we decided to perform additional balloon dilatation of the SVC and innominate vein in 3/5 patients. There were no complications related to the procedure and none of our patients required blood transfusion. Following the intervention, the patients received treatment with low‐molecular‐weight heparin. Interventional treatment achieved persistent patency of the SVC and innominate vein in all patients.
Conclusion
Stent‐retriever thrombectomy is a safe and effective method for interventional treatment of acute thrombosis of the central veins in infants. Due to the large amount of thrombotic material, it is frequently required to combine this method with balloon compression of residual thrombotic material.
Abstract
OBJECTIVES
Whole-body perfusion is the combination of lower body perfusion and antegrade cerebral perfusion. This perfusion technique is used in some centres when performing aortic arch ...reconstruction surgery in neonates and infants. Several studies have shown intra- and postoperative benefits of this technique. However, no studies have analysed the impact it may have on the transfusion of blood products and coagulation factors.
METHODS
We retrospectively analysed 65 consecutive neonates and infants who underwent aortic arch reconstruction surgery from January 2014 to July 2020. Patients operated from 2014 to 2017 underwent surgery with antegrade cerebral perfusion; in patients who underwent surgery from 2017 to 2020 a whole-body perfusion strategy was used. Demographic, intra- and postoperative parameters were compared as well as intraoperative blood product and coagulation factor transfusions, chest-tube output in the first 24 h and postoperative bleeding complications.
RESULTS
Both groups required intraoperative transfusion of red blood cells, fresh frozen plasma, and platelets, as well as substitution of coagulation factors. The amount of transfused volumes of red blood cells, fresh frozen plasma and platelets (P-values 0.01, <0.01 and <0.01) and intraoperative transfusions of fibrinogen and von Willebrand factor were significantly lower in the whole-body perfusion group (P-value 0.04 and <0.01).
CONCLUSIONS
A whole-body perfusion strategy may lead to fewer intraoperative blood product and coagulation factor transfusions when compared to antegrade cerebral perfusion alone in neonates and infants undergoing complex aortic arch reconstruction surgery.
Aortic arch reconstruction surgery represents a challenge for the whole team involved in the treatment of these complex patients, especially in neonates and infants.
Introduction: Chronic pleural cerebrospinal fluid (CSF) effusion is a rare complication after ventriculoperitoneal (VP) shunt insertion and only 18 cases in children and adults have been described so ...far without catheter dislocation to the intrathoracic cavity. Case Presentation: We report on a 4-year-old girl with a complex history of underlying neurogenetic disorder, a hypoxic-ischemic encephalopathy after influenza A infection with septic shock and severe acute respiratory distress syndrome, followed by meningitis at the age of 10 months. In consequence, she developed a severe cerebral atrophy and post-meningitic hydrocephalus requiring placement of a VP shunt. At age 4, she was admitted with community-acquired mycoplasma pneumonia and developed increasing pleural effusions leading to severe respiratory distress and requiring continuous chest tube drainage (up to 1,000–1,400 mL/day) that could not be weaned. β trace protein, in CSF present at concentrations >6 mg/L, was found in the pleural fluid at low concentrations of 2.7 mg/L. An abdomino-thoracic CSF fistula was finally proven by single photon emission computerized tomography combined with low-dose computer tomography. After shunt externalization, the pleural effusion stopped and the chest tube was removed. CSF production rate remains high above 500 mL/24 h. An atrial CSF shunt could not be placed, since a hemodynamically relevant atrial septum defect with frail circulatory balance would not have tolerated the large CSF volumes. Therefore, she underwent a total bilateral endoscopic choroid plexus laser coagulation (CPC) within the lateral ventricles via bi-occipital burr holes. Postoperatively CSF production rate went close to 0 mL and after external ventricular drain removal no signs and symptoms of hydrocephalus developed during a follow-up of now 2.5 years. Conclusion: In summary, pleural effusions in patients with VP shunt can rarely be caused by an abdomino-thoracic fistula, with non-elevated β-trace protein in the pleural fluid. The majority of reported cases in literature were treated by ventriculoatrial shunt. This is the 2nd reported case, which has been successfully treated by radical CPC alone including the temporal horn choroid plexus, making the child shunt independent.
