Association Between Plasma Fibrinogen Concentration After Cardiopulmonary Bypass and Postoperative Blood Loss in Children Undergoing Cardiac Surgery: A Retrospective Cohort Study.

Background Intraoperative hypofibrinogenemia is a major factor associated with increased postoperative blood loss in adult cardiac surgery. However, previous pediatric studies on this topic did not sufficiently adjust for potential confounders and variations in surgeons' techniques. Therefore, evidence for the association between hypofibrinogenemia and postoperative blood loss after cardiac surgery in children remains insufficient. In this study, we aimed to evaluate the association between postoperative blood loss and hypofibrinogenemia by adjusting for potential confounders and the effects of differences in surgeons' techniques. Methodology This single-center, retrospective, cohort study included children who underwent cardiac surgery with cardiopulmonary bypass from April 2019 to March 2022. Multilevel logistic regression models with mixed effects were used to evaluate the association of major blood loss in the first six hours postoperatively with fibrinogen concentration at the end of cardiopulmonary bypass. The difference in the surgeon's techniques was adjusted as a random effect for the model. The model included potential confounders identified as risk factors in previous studies. Results A total of 401 patients were included. A fibrinogen concentration ≤150 mg/dL (adjusted odds ratio (aOR) = 2.08; 95% confidence interval (CI) = 1.18-3.67; p = 0.011) and the presence of cyanotic disease (aOR = 2.34; 95% CI = 1.10-4.97; p = 0.027) were associated with major blood loss in the first six postoperative hours. Conclusions A fibrinogen concentration ≤150 mg/dL and the presence of cyanotic disease were associated with postoperative blood loss in pediatric cardiac surgery. Maintaining a fibrinogen concentration >150 mg/dL is recommended, especially for patients with cyanotic diseases.

Lessons Learned in Neurodevelopmental Outcomes Research in Children Following Extracorporeal Membrane Oxygenation.

Neurodevelopmental outcomes research in children following extracorporeal membrane oxygenationis a complex and evolving field. From systematic reviews to multi-center prospective cohort studies, a variety of research endeavors in this domain have already been conducted. Recent attention has redirected the focus on biomarkers and imaging studies to help better understand the neurological, developmental, and behavioral effects of extracorporeal membrane oxygenation on surviving children. This review provides an overview of major research in the field, ongoing and future studies, and a summary of lessons learned from these efforts.

Memory Problems in Children With Congenital Heart Disease: A Narrative Review.

INTRODUCTION: Care for congenital heart diseases (CHD) has improved significantly over the past several decades, and children with CHD are now surviving into adulthood. Cognitive and behavioral problems affect children with CHD more than healthy peers. A review of performance on neuropsychological memory tasks has not been reported. We aimed to summarize the published literature on memory problems in people with CHD. METHODS: We searched Pubmed, Medline, and PsycINFO from January 1, 1986 to March 22, 2022 to reflect modern care for people with CHD. Our inclusion criteria were randomized controlled trials or observational studies that included children with CHD older than age 3 years, which reported the results of at least 1 neuropsychological test of memory in the CHD group. Our exclusion criteria were studies that included heart transplant recipients and studies that included children who required extracorporeal membrane oxygenation. RESULTS: Thirty-one studies that met our inclusion criteria and avoided exclusion criteria were included in this review. Several studies reported deficits in the subdomains of short-term and long-term memory and visual and verbal memory, though we found substantial heterogeneity across studies. The most likely subdomain to be affected in children with CHD appears to be short-term visual memory. CONCLUSIONS: There is likely an increased risk of memory problems for children and adults with CHD. We were unable to quantify the risk of memory problems due to the heterogeneity of published studies. Future research should make efforts to account for confounding variables and standardize outcome measures.

Measurement of Cardiac Output Using an Ultrasonic Cardiac Output Monitor (USCOM) in Patients with Single-Ventricle Physiology.

We evaluate the validity of cardiac index (CI) measurements utilizing the Ultrasonic Cardiac Output Monitor (USCOM), a non-invasive Doppler ultrasound device, by comparing measurements to cardiac catheterization-derived CI measurements in patients with single-ventricle physiology. USCOM measurements were repeated three times for each patient at the beginning of a cardiac catheterization procedure for twenty-six patients undergoing elective pre-Glenn or pre-Fontan catheterization. CI was measured by USCOM and was calculated from cardiac catheterization data using Fick's method. Bland-Altman analysis for CI showed bias of 0.95 L/min/m2 with the 95% limits of agreement of - 1.85 and 3.75. Pearson's correlation coefficient was 0.89 (p < 0.001) indicating a strong positive relationship between USCOM and cardiac catheterization CI measurements. When excluding two patients with significant dilation of the neo-aortic valve (z-score > + 5), the bias improved to 0.66 L/min/m2 with the 95% limits of agreement of - 1.38 and 2.70. Percent error of limits of agreement was 34%. There was excellent intra-operator reproducibility of USCOM CI measurements with an intra-class coefficient of 0.96. We demonstrate the use of USCOM to measure CI in patients with single-ventricle physiology for the first time, showing acceptable agreement of the CI measurements between USCOM and cardiac catheterization with a high intra-operator reproducibility.

Insights into Fibrinogen-Mediated COVID-19 Hypercoagubility in Critically Ill Patients.

Coronavirus disease-2019 (COVID-19) is associated with hypercoagulability that may cause thromobembolic complications. We describe our recent studies investigating the mechanisms of hypercoagulability in patients with severe COVID-19 requiring mechanical ventilation during the COVID-19 crisis in New York City in spring 2020. Using rotational thombelastometry we found that almost all patients with severe COVID-19 had signs of hypercoagulability compared with non-COVID-19 controls. Specifically, the maximal clot firmness in the fibrin-based extrinsically activated test was almost twice the upper limit of normal in COVID patients, indicating a fibrin-mediated cause for hypercoagulability. To better understand the mechanism of this hypercoagulability we measured the components of the fibrinolytic pathways. Fibrinogen, tissue plasminogen activator and plasminogen activator inhibitor-1, but not plasminogen levels were elevated in patients with severe COVID-19. Our studies indicate that hypercoagulability in COVID-19 may be because of decreased fibrinolysis resulting from inhibition of plasmin through high levels of plasminogen activator inhibitor-1. Clinicians creating treatment protocols for anticoagulation in critically ill COVID-19 patients should consider these potential mechanisms of hypercoaguability.

Reaching Parents Through an Online Community.

Scientific studies in animal models have demonstrated the neurotoxic effects of anesthetic and sedative drugs on the developing brain. Human studies, however, have been limited and less conclusive. The implications for clinical care remain unclear, and there is a critical need for further research on anesthetic toxicity to ensure safe anesthesia practices for infants and children. The sixth PANDA Symposium organized a session on "Engaging Stakeholders to Support Research" to facilitate dialog around improving communication and collaboration among stakeholders and to promote coordinated research efforts. Key stakeholders include patients, families, clinicians, researchers, community organizations, and federal agencies. This article provides an overview of an online platform called the Family Talkboard, a novel method which is destined to enhance patient outreach, engagement, and quality improvement, as well as outcomes research.

Differences in postoperative maladaptive behavioral changes between partial and total tonsillectomy patients.

INTRODUCTION: Behavioral difficulties associated with sleep-disordered breathing (SDB) improve after tonsillectomy, but surgery may lead to the development of short-term postoperative maladaptive behavioral changes (PMBCs). These PMBCs have not been compared between total and partial tonsillectomy patients. METHODS: SDB patients aged 1-6 years undergoing tonsillectomy were recruited. Parent phone surveys were conducted at 48-72 hours and 1-2 weeks postoperatively. Parents identified PMBCs using the Post-Hospital Behavior Questionnaire (PHBQ), scoring changes in behavior compared to baseline. PMBCs were defined by PHBQ scores >0 and compared by one-tailed t-test. Postoperative pain was categorized as mild, moderate, and severe pain using the Parents' Postoperative Pain Measure (PPPM). Differences in pain levels were analyzed by Chi-squared test. A p-value <0.05 was deemed statistically significant. RESULTS: Seventy-eight children completed the study, with 29 total tonsillectomy and 49 partial tonsillectomy patients. At both time points after surgery, PHBQ scores were higher in total tonsillectomy patients than in partial tonsillectomy patients (3.41 ±â€¯3.53 versus 1.94 ±â€¯2.25 at 2-3 days, p = .013). PMBCs were also more frequent in total than partial tonsillectomy patients (76% versus 59% at 2-3 days; 28% versus 7% at 1-2 weeks). Meanwhile, distribution of pain levels was similar between both partial and total tonsillectomy patients. CONCLUSIONS: Our study indicates that total tonsillectomy patients more frequently experience PMBCs than do partial tonsillectomy patients despite similar distributions in pain levels postoperatively. This difference in PHBQ scores between total and partial tonsillectomy patients should be further explored.

Factors influencing postoperative pain following discharge in pediatric ambulatory surgery patients.

STUDY OBJECTIVE: To identify demographic, intraoperative, and parental factors that influence the postoperative pain experience in ambulatory surgery pediatric patients. We also monitored postoperative maladaptive behavior changes (PMBCs) to investigate the relationship between pain and PMBCs. DESIGN: Prospective cohort study. SETTING: Discharge period after ambulatory surgery. PATIENTS: 204 patients ages 1-6years undergoing ambulatory orthopedic, urology, general surgery, and otolaryngology surgical procedures who were American Society of Anesthesiologists (ASA) physical status I or II. INTERVENTIONS: None. MEASUREMENTS: We administered telephone questionnaires to parents of ambulatory surgery patients 1-6years old exploring pain ratings, behavior change ratings, and medication compliance at 2-3days and 1-2weeks after surgery. Pain and behavioral change scores were obtained using the Parents Postoperative Pain Measure (PPPM) and Post-Hospital Behavior Questionnaire (PHBQ). Parental medication compliance was defined as parents who followed the discharge instructions for pain medication administration. MAIN RESULTS: For our cohort, 69% of patients experienced pain after 2-3days and 17% after 1-2weeks post-discharge. PMBCs were reported in 55% after 2-3days, and in 15% after 1-2weeks. In addition, PMBCs occurred in the absence of pain (PPPM=0) at rates of 20% and 5% at 2-3days and 1-2weeks after surgery, respectively. Female sex, anesthesia duration, and otolaryngology procedures correlated with higher postoperative pain (PPPM) scores in univariate and multivariate analysis. Intraoperative medications did not correlate with PPPM or PHBQ scores. Higher pain scores were associated with parents who were compliant with discharge instructions for pain medications. CONCLUSIONS: Many pediatric patients experienced short-term pain and PMBCs after ambulatory surgery, but these largely resolved by 1-2weeks following discharge. Patient sex, anesthesia duration, and surgical procedure influenced postoperative pain and/or PMBCs. Furthermore, PMBCs were associated with, but not solely a manifestation of, postoperative pain.

Use of Anesthesia for Imaging Studies and Interventional Procedures in Children.

Ongoing investigation from the Pediatric Anesthesia NeuroDevelopment Assessment (PANDA) study hopes to examine the long-term effect on cognitive and language development of a single anesthetic exposure in children undergoing inguinal hernia repair. The fifth PANDA Symposium, held in April 2016, continued the mission of previous symposia to examine evidence from basic science and clinical studies on potential neurotoxic effects of anesthetics on developing brain. At the 2016 Symposium, a panel of specialists from nonsurgical pediatric disciplines including anesthesiology, radiology, neurology, gastroenterology, oncology, cardiology, and critical care reviewed use of anesthesia in their practices, including how concern over possible neurodevelopmental effects of early childhood anesthetic exposure has changed discussion with patients and families regarding risks and benefits of imaging studies and interventional procedures involving sedation or anesthesia. This paper summarizes presentations from nonsurgical pediatric specialists at the 2016 PANDA Symposium.

Anesthesia in children: perspectives from nonsurgical pediatric specialists.

The Pediatric Anesthesia NeuroDevelopment Assessment (PANDA) study investigates the potential neurotoxicity of anesthetics in the pediatric population. At a recent symposium, a panel of nonsurgical physicians from the disciplines of radiology, neurology, cardiology, and critical care discussed the role anesthesia plays in their respective practices. To execute diagnostic studies and/or therapeutic interventions in each of these disciplines, general anesthesia is oftentimes required for pediatric patients. Given recent publications in the literature suggesting the potential for neurotoxicity following anesthesia in pediatric patients, physicians, parents, and other stakeholders are now challenged to continue to balance safety with efficacy in caring for children. This paper summarizes the panelist presentations and the ensuing discussion at the 2014 PANDA symposium.

Postoperative cognitive function following general versus regional anesthesia: a systematic review.

The effect of anesthetic technique on postoperative outcomes remains in question. This systematic review compares the role of regional versus general anesthesia, with a particular focus on postoperative cognitive function. Potentially relevant articles were identified by searching publicly available computerized databases for this systematic review. Any surgical procedure was accepted with the exception of cardiac, carotid, and neurosurgical procedures. Any regional anesthetic technique was accepted unless combined with a general anesthetic or in conjunction with propofol as a sedative. Any measure of postoperative cognitive function was accepted as long as it was performed no sooner than 7 days postoperatively. Sixteen studies met inclusion criteria and were included in the final analysis. Three studies showed some difference in cognitive function between regional and general anesthesia, whereas the remaining 13 showed no difference between regional and general anesthesia on postoperative cognitive function.