Perioperative effects of alpha-stat versus ph-stat strategies for deep hypothermic cardiopulmonary bypass in infants

Plessis, Adré J. du; Jonas, Richard A.; Wypij, David; Hickey, Paul R.; Riviello, James J.; Wessel, David; Roth, Stephen J.; Burrows, Frederick A.; Walter, Gene; Farrell, David M.; Walsh, Amy Z.; Plumb, C.; Nido, Pedro J. del; Burke, Redmond P.; Castañeda, Aldo R.; Mayer, John E.; Newburger, Jane W.

doi:10.1016/s0022-5223(97)70013-8

Cited by 271 publications

(127 citation statements)

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“…Because these values were not measured consistently at all sites and with a decreasing frequency during the study infusion, only limited conclusions can be drawn from these data. Consistent with previous studies, [2][3][4][5]15 the lowest mixed venous oxygen saturations and highest lactate values occurred in the first 12 hours after surgery. Although no statistically significant differences were identified between treatment groups, there was a trend toward a wider difference between arterial and mixed venous oxygen saturations at 8 and 12 hours after surgery in the placebo arm compared with those treated with high-dose milrinone (Figure 5, PϽ0.07).…”

Section: Secondary End Pointssupporting

confidence: 91%

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Efficacy and Safety of Milrinone in Preventing Low Cardiac Output Syndrome in Infants and Children After Corrective Surgery for Congenital Heart Disease

et al. 2003

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Background-Low cardiac output syndrome (LCOS), affecting up to 25% of neonates and young children after cardiac surgery, contributes to postoperative morbidity and mortality. This study evaluated the efficacy and safety of prophylactic milrinone in pediatric patients at high risk for developing LCOS. Methods and Results-The study was a double-blind, placebo-controlled trial with 3 parallel groups (low dose, 25-g/kg bolus over 60 minutes followed by a 0.25-g/kg per min infusion for 35 hours; high dose, 75-g/kg bolus followed by a 0.75-g/kg per min infusion for 35 hours; or placebo). The composite end point of death or the development of LCOS was evaluated at 36 hours and up to 30 days after randomization. Among 238 treated patients, 25.9%, 17.5%, and 11.7% in the placebo, low-dose milrinone, and high-dose milrinone groups, respectively, developed LCOS in the first 36 hours after surgery. High-dose milrinone significantly reduced the risk the development of LCOS compared with placebo, with a relative risk reduction of 55% (Pϭ0.023) in 238 treated patients and 64% (Pϭ0.007) in 227 patients without major protocol violations. There were 2 deaths, both after infusion of study drug. The use of high-dose milrinone reduced the risk of the LCOS through the final visit by 48% (Pϭ0.049). Conclusions-The use of high-dose milrinone after pediatric congenital heart surgery reduces the risk of LCOS.

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Section: Secondary End Pointssupporting

confidence: 91%

“…This fall in cardiac index was associated with an elevated systemic vascular resistance of Ϸ25% and a rise in pulmonary vascular resistance of nearly 40% from baseline values. Other recent reports document similar hemodynamic 3,4 and respiratory 5 findings after surgery in neonates and young infants.…”

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confidence: 67%

Efficacy and Safety of Milrinone in Preventing Low Cardiac Output Syndrome in Infants and Children After Corrective Surgery for Congenital Heart Disease

et al. 2003

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“…l~ There is evidence, too, that a brief period of cold reperfusion ss-6~ or a slower rate of rewarming may be beneficial, s7 In addition, newer data have challenged the widely held notion that alpha-star strategy of acid-base management is superior to pH-stat strategy for organ protection during deep hypothermic CPB in infants. 67 Unfortunately, the lack of uniformity of procedures, equipment or management in paediatric open-heart surgery makes comparison of clinical practices in different institutions and scientific studies difficult to assess. Large mulficentre outcome studies are needed to help identify the techniques and strategies associated with better neurological and developmental outcomes.…”

Section: Resultsmentioning

confidence: 99%

Cerebral physiology in paediatric cardiopulmonary bypass

Pua

Bissonnette

1998

Can J Anaesth

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FKCPCPurpose: To analyze studies of neurological injury after open-heart surgery in infants and children and to discuss the effects of cardiopulmonary bypass, hypothermia and deep hypothermic circulatory arrest on cerebral blood flow, cerebral metabolism and brain temperature. Source: Articles were obtained from the databases, Current Science and Medline, from 1966 to present. Search terms include cardiopulmonary bypass(CPB), hypothermia, cerebral blood flow(CBF), cerebral metabolism and brain temperature. Information and abstracts obtained from meetings on the topic of brain and cardiac surgery helped complete the collection of information. Principal findings: In adults the incidence of neurological morbidity is between 7 to 87% with stroke in about 2-5%, whereas the incidence of neurological morbidity increases to 30% in infants and children undergoing cardiopulmonary bypass. Besides the medical condition of the patient, postoperative cerebral dysfunction and neuronal ischaemia associated with cardiac surgery in infants and small children are a combination of intraoperative factors. Deep hypothermic circulatory arrest impairs CBF and cerebral metabolism even after termination of CPB. Inadequate and/or non-homogenous cooling of the brain before circulatory arrest, as well as excessive rewarming of the brain during reperfusion are also major contributory factors. Conclusion: Newer strategies, including the use of low-flow CPB, pulsatile CPB, pH-stat acid-base management and a cold reperfusion, are being explored to ensure better cerebral protection, Advances in monitoring technology and better understanding of the relationship of cerebral blood flow and metabolism during the different modalities of cardiopulmonary bypass management will help in the medical and anaesthetic development of strategies to improve neurological and developmental outcomes.Objectif: Examiner les Etudes portant sur les atteintes neurologiques survenues apr& une chirurgie b. coeur ouvert chez les bEbEs et les enfants et discuter des effets de la circulation extracorporelle, de l'hypothermie et de l'arr~t circulatoire sous hypothermie profonde sur le debit sanguin c&~bral, sur le m&abolisme c&Ebral et sur la temperature du cerveau. Sources documentaires : Des articles ont &E choisis ~ partir de bases de donnEes, Current Science et Medline, de 1966 ~ aujourd'hui. Les mots-cl& utilis& Etaient : circulation extracorporelle (CEC), hypothermie, debit sanguin cErEbral (DSC), mEtabolisme cErEbral et temperature du cerveau. Les informations et les rEsumEs obtenus & la suite de sEminaires sur le cerveau et la chirurgie cardiaque ont permis de completer la cueillette de donn&s. I)onn&s principales : Chez les adultes, l'incidence de morbiditE neurologique avec accident vasculaire est de 7 87 % clans 2 ~. S % des cas tandis que l'incidence de morbiditE neurologique augmente & 30 % chez les bEb~s et les enfants subissant une circulation extracorporelle. La condition mEdicale du patient raise & part, le d&~glement cErEbral postop&atoire et l'ischEmie neu...

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“…[5][6][7][8][9][10] From these trials, we selected for analysis those subjects with a diagnosis of D-TGA with IVS or VSD and repair by primary arterial switch operation. All trials excluded infants with associated cardiovascular anomalies requiring additional open surgical procedures or recognizable syndromes of congenital anomalies.…”

Section: Subjectsmentioning

confidence: 99%

Effect of Prenatal Diagnosis on Outcomes in D-Transposition of the Great Arteries

Bartlett¹,

Wypij²,

Bellinger³

et al. 2004

Pediatrics

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ABSTRACT. Background. By decreasing preoperative morbidity, prenatal diagnosis could improve neurodevelopmental outcomes in infants with critical congenital heart disease. We explored the impact of prenatal diagnosis on perinatal and perioperative variables and on outcomes at 1 year of age.Methods. We analyzed a database of children enrolled in prospective studies on surgical support techniques from 1988 to 2000. Selection criteria included a diagnosis of D-transposition of the great arteries with intact ventricular septum or ventricular septal defect, no extracardiac congenital anomalies, birth weight >2.3 kg, and repair by arterial switch procedure.Results. Of 346 patients at enrollment, 25 had a prenatal diagnosis, and 321 did not. Children with prenatal diagnosis, compared with those without, had a lower likelihood of birth by spontaneous labor, lower birth weights, lower Apgar 5 scores, a higher rate of preoperative endotracheal intubation, and surgery at a younger age. They tended to have a lower incidence of fetal distress during labor. At 1 year of age, 272 patients were tested with the Psychomotor Development Index and Mental Development Index of the Bayley Scales. Mean z scores were similar in those with and without prenatal diagnosis for both Psychomotor Development Index (؊0.92 ؎ 0.93 vs ؊0.88 ؎ 1.05) and Mental Development Index (؊0.29 ؎ 1.13 vs ؊0.41 ؎ 0.93).Conclusions. Infants with D-transposition of the great arteries with and without prenatal diagnosis differed with respect to perinatal and perioperative variables, but their development at 1 year of age was similar. Future studies should include a greater number of children with prenatal diagnosis and a variety of congenital heart lesions. Pediatrics 2004;113:e335-e340. URL: http: //www.pediatrics.org/cgi/content/full/113/4/e335; congenital heart disease, transposition of the great arteries, cardiac surgery, child development, prenatal diagnosis.ABBREVIATIONS. CHD, congenital heart disease; D-TGA, Dtransposition of the great arteries; IVS, intact ventricular septum; VSD, ventricular septal defect; PDI, Psychomotor Development Index; MDI, Mental Development Index; SD, standard deviation. P renatal echocardiography is being performed with increasing frequency to identify complex congenital heart disease (CHD) in the fetus. It has been hypothesized that prenatal diagnosis of CHD might allow for optimal medical management in the newborn period, thereby improving surgical and neurologic outcomes. 1 Previous studies have examined the impact of a prenatal diagnosis on neonatal mortality and morbidity. 2,3 However, advances in surgical technology and perioperative management have improved survival of children born with CHD, thereby heightening interest in their subsequent developmental outcomes. 4 Presently, data are limited regarding the impact of prenatal diagnosis on longer-term cognitive development in children born with CHD.Prenatal diagnosis of D-transposition of the great arteries (D-TGA) allows a controlled environment for delivery, timely tran...

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Perioperative effects of alpha-stat versus ph-stat strategies for deep hypothermic cardiopulmonary bypass in infants

Cited by 271 publications

References 22 publications

Efficacy and Safety of Milrinone in Preventing Low Cardiac Output Syndrome in Infants and Children After Corrective Surgery for Congenital Heart Disease

Efficacy and Safety of Milrinone in Preventing Low Cardiac Output Syndrome in Infants and Children After Corrective Surgery for Congenital Heart Disease

Cerebral physiology in paediatric cardiopulmonary bypass

Effect of Prenatal Diagnosis on Outcomes in D-Transposition of the Great Arteries

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