Early initiation of arginine vasopressin infusion in neonates after complex cardiac surgery*

Alten, Jeffrey A.; Borasino, Santiago; Toms, Rune; Law, Mark A.; Moellinger, Ashley; Dabal, Robert J.

doi:10.1097/pcc.0b013e31822f1753

Cited by 57 publications

(33 citation statements)

References 20 publications

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“…The highest post-operative plasma FABP2 concentrations were seen for children on vasopressin and epinephrine infusions. Vasopressin is used as a vasopressor in children with CHD, but may have negative effects on the intestinal epithelial barrier through restriction in splanchnic blood flow 25 . In this single-center pilot investigation it is not possible to determine if type or dose of vasoactive infusion alters intestinal barrier function, or if intestinal barrier dysfunction is indicative of severity of illness.…”

Section: Resultsmentioning

confidence: 99%

Clinical Characteristics Associated With Postoperative Intestinal Epithelial Barrier Dysfunction in Children With Congenital Heart Disease*

Typpo

Larmonier

Deschenes

et al. 2015

Pediatric Critical Care Medicine

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Objective Children with congenital heart disease (CHD) have loss of intestinal epithelial barrier function (EBF), which increases their risk for post-operative sepsis and organ dysfunction. We do not understand how post-operative cardiopulmonary support or the inflammatory response to cardiopulmonary bypass (CPB) might alter intestinal EBF. We examined variation in a panel of plasma biomarkers to reflect intestinal EBF (cellular and paracellular structure and function) after CPB and in response to routine ICU care. Design Prospective cohort Setting University medical center cardiac intensive care unit Patients Twenty children aged newborn to 18 years undergoing repair or palliation of CHD with CPB. Interventions We measured baseline and repeated plasma FABP2, citrulline, claudin 3, and dual sugar permeability test (DSPT) to reflect intestinal epithelial integrity, epithelial function, paracellular integrity, and paracellular function, respectively. We measured baseline and repeated plasma pro-inflammatory (IL-6, TNF-α, IFN-γ) and anti-inflammatory (IL4, IL10) cytokines, known to modulate intestinal EBF in murine models of CPB. Measurements and Main Results All patients had abnormal baseline FABP2 concentrations (mean 3815.5 pg/mL), (normal 41–336 pg/mL). Cytokine response to CPB was associated with early, but not late changes in plasma concentrations of FABP2 and citrulline. Variation in biomarker concentrations over time were associated with aspects of ICU care indicating greater severity of illness: claudin 3, FABP2, and DSPT ratio were associated with symptoms of feeding intolerance (p<0.05) while FABP2 was positively associated with vasoactive-inotrope score (VIS) (p=0.04). Citrulline was associated with larger arteriovenous O2 saturation difference (p=0.04) and had a complex relationship with VIS. Conclusions Children undergoing CPB for repair or palliation of CHD are at risk for intestinal injury and often present with evidence for loss of intestinal epithelial integrity pre-operatively. Greater severity of illness requiring increased cardiopulmonary support rather than the inflammatory response to CPB seems to mediate late post-operative intestinal EBF.

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Section: Resultsmentioning

confidence: 99%

Clinical Characteristics Associated With Postoperative Intestinal Epithelial Barrier Dysfunction in Children With Congenital Heart Disease*

Typpo

Larmonier

Deschenes

et al. 2015

Pediatric Critical Care Medicine

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“…Del Nido cardioplegia was utilized for aortic cross clamp. Postoperative management was protocolized to target age- and physiology-specific hemodynamic and respiratory goals via inotrope titration, colloid boluses, and ventilator adjustments as described elsewhere [10]. We followed a fluid restrictive protocol including 25% maintenance intravenous fluids during the first 24-hours and maximally concentrated infusions.…”

Section: Methodsmentioning

confidence: 99%

Hypogammaglobulinemia after cardiopulmonary bypass in infants

Rhodes

Robert

Atkinson

et al. 2014

The Journal of Thoracic and Cardiovascular Surgery

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Background Hypogammaglobulinemia has been reported after cardiac surgery and may be associated with adverse outcomes. We sought to define baseline immunoglobulin (Ig) concentration in neonates and infants with congenital heart disease, determine its course following cardiopulmonary bypass (CPB), and determine if post-CPB hypogammaglobulinemia was associated with increased morbidity. Methods Single center, retrospective analysis of infants who underwent cardiac surgery with CPB between June 2010 and December 2011. Ig concentration obtained from banked plasma of 47 patients from a prior study (pre-CPB, immediately post-CPB, and 24- and 48-hours post-CPB). Additionally, any Ig levels drawn for clinical purposes after CPB were included. Ig levels were excluded if drawn after chylothorax diagnosis or intravenous immunoglobulin G administration. Results Median age was 7 days. Preoperative Ig concentration was similar to that described in healthy children. IgG level fell to less than 50% of preoperative concentration by 24-hr post-CPB and failed to recover by 7 days. 25/47 (53%) patients had low IgG after CPB (<248 mg/dl). Despite no difference in demographics or risk factors between patients with low and normal IgG, low IgG patients had more positive fluid balance at 24-hours, increased pro-inflammatory plasma cytokine levels, duration of mechanical ventilation, and CICU length of stay. Additionally, low IgG patients had increased incidence of post-operative infections (40% vs. 14%, p=0.056). Conclusions Hypogammaglobulinemia occurs in half of infants after CPB. Its association with fluid overload and increased inflammatory cytokines suggests it may result from capillary leak. Postoperative hypogammaglobulinemia is associated with increased morbidity, including more secondary infections.

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“…Experience with AVP/TP in neonates has been more focused on term newborns with congenital heart disease who develop hypotension after surgery, newborns with PPHN or with septic shock all reporting increased blood pressure, most reporting increased urine output and some reporting decreased lactate levels coming from retrospective studies or case series [85,[90][91][92][93][94][95].…”

Section: Evidence and Pd Effectsmentioning

confidence: 99%

Cardiovascular Drug Therapy for Human Newborn: Review of Pharmacodynamic Data

Ergenekon

Rojas-Anaya

Bravo

et al. 2018

CPD

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Background: Circulatory failure in preterm and term newborn infants is commonly treated with inotropes or vasoactive medications. In this structured literature review the available data on pharmacodynamic effects of the inotropes adrenaline, dobutamine, dopamine, levosimendan, milrinone, noradrenaline, and the vasoactive drugs vasopressin and hydrocortisone are presented. Methods: Structured searches were conducted to identify relevant articles according to pre-defined inclusion criteria which were human clinical trials published after 2000.Results: Out of 101 identified eligible studies only 22 studies met the criteria for evidence based practice guidelines level I to IV. The most prevalent pharmacodynamic effects were increase in blood pressure and/or heart rate, which were also the most frequently studied circulatory parameters. Conclusion: This review demonstrates the need for further systematic studies on all reviewed drugs with incorporation of novel noninvasive biomarkers in this vulnerable patient group, for more timely and appropriate treatment for clinical efficacy.

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Early initiation of arginine vasopressin infusion in neonates after complex cardiac surgery*

Abstract: Low-dose arginine vasopressin infusion initiated in the operating room after complex neonatal cardiac surgery was associated with decreased fluid resuscitation and catecholamine requirements in the first 24 postoperative hours.

Cited by 57 publications

References 20 publications

Clinical Characteristics Associated With Postoperative Intestinal Epithelial Barrier Dysfunction in Children With Congenital Heart Disease*

Clinical Characteristics Associated With Postoperative Intestinal Epithelial Barrier Dysfunction in Children With Congenital Heart Disease*

Hypogammaglobulinemia after cardiopulmonary bypass in infants

Cardiovascular Drug Therapy for Human Newborn: Review of Pharmacodynamic Data

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