Update: Advances in Pediatric Cardiac Intensive Care

Pediatric cardiac critical care continuously makes significant efforts in improving perioperative management strategies, optimizing outcomes, and thereby reducing morbidity and mortality. During the past 2 years, major topics in research and development were as follows:

A. Acute renal failure. The occurrence of acute kidney injury (AKI) according to pediatric RIFLE (pRIFLE) criteria has a major impact on adverse outcomes in children after heart surgery. Risk factors identified were, besides young age, low weight, long bypass times, higher PRISM-score and also hypotension, and the administration of contrast media due to catheter investigation prior to surgery. Various biomarkers have been identified to predict and monitor AKI in this situation. Treatment options include to liberally insert percutaneous peritoneal catheters (PPCs) or prophylactic peritoneal dialysis to manage fluid balance, thereby improve ventilatory function and improve outcome.

B. Steroids. Neonatal cardiac surgery results in a heightened inflammatory response, and perioperative glucocorticoid administration is commonly used in an attempt to reduce the inflammatory cascade. A higher dose of glucocorticoids (GCs) administered prior to cardiopulmonary bypass (CPB) is effective at suppressing the inflammatory response to CPB and leads to an improved postoperative course. There are highly variable approaches in administration. The addition of a preoperative dose of methylprednisolone to a standard intraoperative methylprednisolone dose does not improve markers of inflammation after neonatal cardiac surgery. It may show significantly less complement activation postoperatively, and clinical outcome, however, is not improved. A greater cumulative duration of corticosteroid exposure may independently be associated with postoperative infection.

C. Transfusion. Transfusion is common following cardiopulmonary bypass (CPB) in children, and the incidence and volume of blood transfusion is associated with increased mortality, and markedly affects postoperative morbidity including infection, and duration of mechanical ventilation. Transfusion in pediatric cardiac surgery is often based on clinical judgment rather than objective data. Introduction of objective transfusion algorithms significantly reduce perioperative blood product utilization and mortality, without increasing postoperative chest tube losses. Cell saver blood can be safely stored at the bedside for immediate transfusion for 24 hours after collection; its use significantly reduces the number of RBC and coagulant product transfusions and donor and has the potential to reduce transfusion-associated complications and decrease postoperative morbidity.

D. Nutritional aspects. Infants with congenital heart lesions who undergo open heart surgery may experience physiologic and metabolic stress in the postoperative period, leading to altered metabolism and hypercatabolism. Many patients are malnourished at surgery; lower total body fat mass and acute and chronic malnourishment are associated with worse clinical outcomes; providing inadequate energy intake is associated with adverse pediatric intensive care outcomes, with a significantly increased duration of artificial ventilation, time to chest closure, time in intensive care, and hospital stay. Only two-thirds of the patients recommended that their caloric and protein requirements were provided by week 1. There is a correlation between total body fat mass and BNP levels. Duration of inotropic support and BNP increase concomitantly as measures of nutritional status decrease, such as the levels of thyroid hormones, supporting the hypothesis that malnourishment is associated with decreased myocardial function.

Bibliography:

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