Mid-regional pro-adrenomedullin for diagnosing evolution after cardiac surgery in newborns: the PRONEW study.

Newborns are the most vulnerable patients after cardiac surgery. Although mortality risk scores before surgery may help predict the risk of poor outcome, new tools are required, and biomarkers could add objective data to these tools. The aim of this study was to assess the ability of mid-regional pro-adrenomedullin (pro-ADM) and pro-atrial natriuretic peptide (pro-ANP) to predict poor outcome after cardiac surgery. This is a pilot diagnostic accuracy study that includes newborns and infants under 2 months admitted to an intensive care unit after cardiac surgery. Pro-ADM and pro-ANP were determined immediately upon admission. Poor outcome was defined as mortality, cardiac arrest, requiring extracorporeal support, requiring renal replacement therapy, or neurological injury. Forty-four patients were included. Twenty-six (59%) had a STAT category of ≥ 4. Ten patients (22.7%) presented a poor outcome, four of whom (9.1%) died. Pro-ADM was higher in patients with poor outcome (p = 0.024) and death (p = 0.012). Pro-ADM showed the best area under curve (AUC) for predicting poor outcome (0.735) and mortality alone (0.869). A pro-ADM of 2 nmol/L had a Sn of 75% and a Sp of 85% for predicting mortality. Pro-ADM > 2 nmol/L was independently associated with poor outcome (OR 5.8) and mortality (OR 14.1). Although higher pro-ANP values were associated with poor outcomes, no cut-off point were found. The combination of STAT ≥ 4 and the biomarkers did not enhance predictive power for poor outcome or mortality.Conclusion: Pro-ADM and pro-ANP determined immediately after surgery could be helpful for stratifying risk of poor outcome and mortality in newborns. What is Known: • Some congenital heart diseases must be corrected/palliated during the first days of life. A useful tool to predict the risk of severe complications has not been proposed. • Most unstable newborns would have higher values of biomarkers such as pro-ADM and pro-ANP related to shock and compensatory actions. What is New: • Pro-ADM and pro-ANP seem to be good biomarkers to predict poor outcome after cardiac surgery. A pro-ADM < 2 nmol/L would imply a low likelihood of a poor outcome. • Deepening the analysis of biomarkers can help in making decisions to prevent/treat complications.

Weaning from neonatal and pediatric ECMO with stand-by cannula.

The precise moment for weaning a patient off extracorporeal membrane oxygenation (ECMO) is not always easy to establish. Also, mechanical causes may obligate to disconnect the patient from the circuit before the optimal weaning off. In these selected cases, the patient can be disconnected from the circuit and the cannula can be left in place (stand-by cannula) until the patient's stability without ECMO is assured. The aim was to describe our experience with the stand-by cannula. Single-institution, long-term retrospective study in a pediatric tertiary care hospital. Neonatal and pediatric patients who were under ECMO and needed stand-by cannula before definitive de-cannulation were included. During 18 years, 166 children required ECMO. In 31 patients (18.7%), stand-by cannula was performed before the weaning off. Twenty patients (64.5%) were newborn. The main reason for requiring ECMO in these newborn was persistent pulmonary hypertension. Eleven patients were pediatric and their main cause for requiring ECMO was cardiogenic shock (six patients, 54.4%). The reasons for requiring stand-by cannula were the uncertainty of a successful weaning off in 17 patients (54.8%), to undergo surgery in 10 patients (32.3%) and to replace the circuit in four cases (12.9%). The median duration of stand-by cannula was 12 h (IQR 6-24). Heparinized saline serum was the main maintenance perfusion (28 patients, 90.3%). Three patients needed to restart support with ECMO. Only one mechanical complication was detected. Stand-by cannula is a safe technique, which allows performing a quick re-entrance on ECMO if the weaning off fails.