Prognostic Value of Perioperative Near-Infrared Spectroscopy During Neonatal and Infant Congenital Heart Surgery for Adverse In-Hospital Clinical Events

Dodge-Khatami, Jannika; Gottschalk, U; Eulenburg, Christine; Wendt, Ulrike; Schnegg, Clivia; Rebel, Marcus; Reichenspurner, Hermann; Dodge‐Khatami, Ali

doi:10.1177/2150135111426298

Cited by 17 publications

(19 citation statements)

References 21 publications

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“…Nevertheless, CPB is affected by significant morbidity due to several factors, including extent and duration of blood contact with CPB circuit, hemodilution, and changes in perfusion temperature. Several studies have shown efficacy of cerebral and renal rSO2 in detecting low cardiac output state both during CPB and during intensive care unit (ICU) stay (3,4). Strategies aimed at mitigating SIRS include management of perfusion temperature toward mild hypothermia or normothermia, reduction of hemodilution, circuit miniaturization, and biocompatibility improvement (2).…”

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confidence: 99%

Continuous Metabolic Monitoring in Infant Cardiac Surgery: Toward an Individualized Cardiopulmonary Bypass Strategy

et al. 2015

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Cardiopulmonary bypass (CPB) in infants is associated with morbidity due to systemic inflammatory response syndrome (SIRS). Strategies to mitigate SIRS include management of perfusion temperature, hemodilution, circuit miniaturization, and biocompatibility. Traditionally, perfusion parameters have been based on body weight. However, intraoperative monitoring of systemic and cerebral metabolic parameters suggest that often, nominal CPB flows may be overestimated. The aim of the study was to assess the safety and efficacy of continuous metabolic monitoring to manage CPB in infants during open-heart repair. Between December 2013 and October 2014, 31 consecutive neonates, infants, and young children undergoing surgery using normothermic CPB were enrolled. There were 18 male and 13 female infants, aged 1.4 ± 1.7 years, with a mean body weight of 7.8 ± 3.8 kg and body surface area of 0.39 m(2) . The study was divided into two phases: (i) safety assessment; the first 20 patients were managed according to conventional CPB flows (150 mL/min/kg), except for a 20-min test during which CPB was adjusted to the minimum flow to maintain MVO2>70% and rSO2>45% (group A); (ii) efficacy assessment; the following 11 patients were exclusively managed adjusting flows to maintain MVO2>70% and rSO2>45% for the entire duration of CPB (group B). Hemodynamic, metabolic, and clinical variables were compared within and between patient groups. Demographic variables were comparable in the two groups. In group A, the 20-min test allowed reduction of CPB flows greater than 10%, with no impact on pH, blood gas exchange, and lactate. In group B, metabolic monitoring resulted in no significant variation of endpoint parameters, when compared with group A patients (standard CPB), except for a 10% reduction of nominal flows. There was no mortality and no neurologic morbidity in either group. Morbidity was comparable in the two groups, including: inotropic and/or mechanical circulatory support (8 vs. 1, group A vs. B, P = 0.07), reexploration for bleeding (1 vs. none, P = not significant [NS]), renal failure requiring dialysis (none vs. 1, P = NS), prolonged ventilation (9 vs. 4, P = NS), and sepsis (2 vs. 1, P = NS). The present study shows that normothermic CPB in neonates, infants, and young children can be safely managed exclusively by systemic and cerebral metabolic monitoring. This strategy allows reduction of at least 10% of predicted CPB flows under normothermia and may lay the ground for further tailoring of CPB parameters to individual patient needs.

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confidence: 99%

Continuous Metabolic Monitoring in Infant Cardiac Surgery: Toward an Individualized Cardiopulmonary Bypass Strategy

et al. 2015

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“…Although the cited literature varies widely in range for ACP from 10 to 100 mL/kg/min, studies utilizing NIRS technology or visual light spectroscopy have indicated that ACP flow rates of greater than 30 mL/kg/min are sufficient to maintain adequate cerebral and somatic oxygen saturations (12,19,40). Admittedly, these findings must be evaluated within the context of temperature and blood gas management (pH versus alpha stat) among other factors.…”

Section: Discussionmentioning

confidence: 99%

“…Somatic ischemia is theoretically lessened during arch reconstruction and the risks of neurological and cognitive deficits following operation are presumably reduced (8,9). With increased experience with ACP in the field of adult aortic arch reconstruction, a more recent evolution from deep hypothermia toward the use of warmer temperatures has occurred (10)(11)(12).…”

Section: Introductionmentioning

confidence: 99%

“…In newborns and infants, extended end-to-end repair of coarctation is performed routinely at near-normothermia with all cerebral and systemic perfusion achieved via the innominate artery for periods of approximately 20 minutes, without clinically significant neurological or end-organ injury (17). Notwithstanding, few reports evaluate the use of moderate hypothermia for ACP in neonates and children undergoing aortic arch reconstructions (11,12,(18)(19)(20).…”

Section: Introductionmentioning

confidence: 99%

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Antegrade cerebral perfusion at 25 °C for arch reconstruction in newborns and children preserves perioperative cerebral oxygenation and serum creatinine

et al. 2016

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Background: Antegrade cerebral perfusion (ACP) typically is used with deep hypothermia for cerebral protection during aortic arch reconstructions. The impact of ACP on cerebral oxygenation and serum creatinine at a more tepid 25 ℃ was studied in newborns and children.Methods: Between 2010 and 2014, 61 newborns and children (<5 years old) underwent aortic arch reconstruction using moderate hypothermia (25.0±0.9 ℃) with ACP and a pH-stat blood gas management strategy. These included 44% Norwood-type operations, 30% isolated arch reconstructions, and 26% arch reconstructions with other major procedures. Median patient age at surgery was 9 days (range, 3 days-4.7 years). Cerebral oxygenation (NIRS) was monitored continuously perioperatively for 120 hours.Serum creatinine was monitored daily.Results: Median cardiopulmonary bypass (CPB) and cross clamp times were 181 minutes (range, 82-652 minutes) and 72 minutes (range, 10-364 minutes), respectively. ACP was performed at a mean flow rate of 46±6 mL/min/kg for a median of 48 minutes (range, 10-123 minutes). Cerebral and somatic NIRS were preserved intraoperatively and remained at baseline postoperatively during the first 120 hours.Peak postoperative serum creatinine levels averaged 0.7±0.3 mg/dL for all patients. There were 4 (6.6%) discharge mortalities. Six patients (9.8%) required ECMO support. Median postoperative length of hospital and intensive care unit (ICU) stay were 16 days(range, 4-104 days) and 9 days (range, 1-104 days), respectively. Two patients (3.3%) received short-term peritoneal dialysis for fluid removal, and none required hemodialysis. Three patients (4.9%) had an isolated seizure which resolved with medical therapy, and none had a neurologic deficit or stroke.Conclusions: ACP at 25 ℃ preserved perioperative cerebral oxygenation and serum creatinine for newborns and children undergoing arch reconstruction. Early outcomes are encouraging, and additional study is warranted to assess the impact on late outcomes.

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“…Additionally, the application of somatic rSO 2 provides an indicator for renal or lower body perfusion. A cerebral NIRS value below 45% and a renal NIRS value below 40% has a strong correlation with the incidence of ECMO or hospital death and a renal NIRS below 30% correlated with prolonged ICU stay (49,50). This information coupled with standard blood gas and lactate analysis provides a basic picture of perfusion adequacy.…”

Section: Physical Parameter Measurements and Data Capturementioning

confidence: 99%

Recent innovations in perfusion and cardiopulmonary bypass for neonatal and infant cardiac surgery

Sturmer¹,

Beaty²,

Clingan³

et al. 2018

Transl Pediatr

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Abstract:The development and refinement of cardiopulmonary bypass (CPB) has made the repair of complex congenital heart defects possible in neonates and infants. In the past, the primary goal for these procedures was patient survival. Now that substantial survival rates have been achieved for even the most complex of repairs in these patients, focus has been given to the reduction of morbidity. Although a necessity for these complex neonatal and infant heart defect repairs, CPB can also be an important source of perioperative complications. Recent innovations have been developed to mitigate these risks and is the topic of this review. Specifically, we will discuss improvements in minimizing blood transfusions, CPB circuit design, monitoring, perfusion techniques, temperature management, and myocardial protection, and then conclude with a brief discussion of how further systematic improvements can be made in these areas.

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Prognostic Value of Perioperative Near-Infrared Spectroscopy During Neonatal and Infant Congenital Heart Surgery for Adverse In-Hospital Clinical Events

Cited by 17 publications

References 21 publications

Continuous Metabolic Monitoring in Infant Cardiac Surgery: Toward an Individualized Cardiopulmonary Bypass Strategy

Continuous Metabolic Monitoring in Infant Cardiac Surgery: Toward an Individualized Cardiopulmonary Bypass Strategy

Antegrade cerebral perfusion at 25 °C for arch reconstruction in newborns and children preserves perioperative cerebral oxygenation and serum creatinine

Recent innovations in perfusion and cardiopulmonary bypass for neonatal and infant cardiac surgery

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