Cross-sectional prevalence of SARS-CoV-2 antibodies in healthcare workers in paediatric facilities in eight countries.

BACKGROUND: Healthcare workers (HCWs) have been disproportionately affected by coronavirus disease 2019 (COVID-19), which may be driven, in part, by nosocomial exposure. If HCW exposure is predominantly nosocomial, HCWs in paediatric facilities, where few patients are admitted with COVID-19, may lack antibodies to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and be at increased risk during the current resurgence. AIM: To compare the seroprevalence of SARS-CoV-2 amongst HCWs in paediatric facilities in seven European countries and South Africa (N=8). METHODS: All categories of paediatric HCWs were invited to participate in the study, irrespective of previous symptoms. A single blood sample was taken and data about previous symptoms were documented. Serum was shipped to a central laboratory in London where SARS-CoV-2 immunoglobulin G was measured. FINDINGS: In total, 4114 HCWs were recruited between 1st May and mid-July 2020. The range of seroprevalence was 0-16.93%. The highest seroprevalence was found in London (16.93%), followed by Cape Town, South Africa (10.36%). There were no positive HCWs in the Austrian, Estonian and Latvian cohorts; 2/300 [0.66%, 95% confidence interval (CI) 0.18-2.4] HCWs tested positive in Lithuania; 1/124 (0.81%, 95% CI 0.14-4.3) HCWs tested positive in Romania; and 1/76 (1.3%, 95% CI 0.23-7.0) HCWs tested positive in Greece. CONCLUSION: Overall seroprevalence amongst paediatric HCWs is similar to their national populations and linked to the national COVID-19 burden. Staff working in paediatric facilities in low-burden countries have very low seroprevalence rates and thus are likely to be susceptible to COVID-19. Their susceptibility to infection may affect their ability to provide care in the face of increasing cases of COVID-19, and this highlights the need for appropriate preventative strategies in paediatric healthcare settings.

Effects of dexamethasone on clinical course, C-reactive protein, S100B protein and von Willebrand factor antigen after paediatric cardiac surgery.

BACKGROUND: Anti-inflammatory treatment with glucocorticoids during cardiopulmonary bypass can reduce inflammatory mediator release, but the effects of glucocorticoid on outcome are controversial. METHODS: We studied the effects of dexamethasone on clinical course, C-reactive protein, von Willebrand factor antigen (vWf:Ag) and S100B in a randomized masked study of children after open cardiac surgery. Twenty children weighing >10 kg received dexamethasone (1 mg kg(-1)) and 20 controls received saline after induction of anaesthesia. We measured vWf:Ag as a marker of endothelial activation, S100B as a marker of cerebral protein release and C-reactive protein as a marker of inflammatory activity. Oxygenation, body temperature, fluid balance, leucocyte and platelet counts, days in the intensive care unit (ICU) and days on mechanical ventilation were noted. RESULTS: Dexamethasone decreased C-reactive protein concentration on the first postoperative day (P<0.05), but did not affect the release of vWf:Ag or S100B. There was no significant difference in oxygenation, body temperature, fluid balance, leucocyte and platelet counts, days in the ICU or days on mechanical ventilation between the placebo and dexamethasone-treated groups. CONCLUSION: Administration of dexamethasone before cardiopulmonary bypass for paediatric cardiac surgery decreased the inflammatory response, but did not affect the immediate features after surgery or changes in vWf:Ag or S100B.

How common is severe pulmonary hypertension after pediatric cardiac surgery?

BACKGROUND: Pulmonary hypertension may result in significant morbidity and mortality after pediatric cardiac surgery. The objective of this study was to determine the incidence and outcome of severe pulmonary hypertension, defined as a ratio of pulmonary to systemic arterial pressure equal to or greater than 1.0, after cardiac surgery in children. METHODS: Data from all children younger than 18 years who had undergone cardiothoracic surgery from January 1, 1994, to December 31, 1998, were examined. To find children with severe pulmonary hypertension, we reviewed intensive care unit charts from patients who had been monitored with a pulmonary artery catheter after the operation (n = 151), had received mechanical ventilation for more than 4 days after the operation (n = 124), or had died in the operating room or the intensive care unit (n = 22). Intraoperative and postoperative measurements of mean pulmonary arterial pressure and postoperative echocardiographic studies during the first 3 postoperative days were used to select the children. RESULTS: During the study period, 1349 children (including 164 neonates and 511 infants, median age 12 months) underwent cardiac operations with an overall perioperative mortality of 22 patients (1.6%). Twenty-seven children (2%, median age 4.2 months) had severe pulmonary hypertension. Of these, 2 (7.4%) died within 30 days of the operation, and 3 others (11%) died within a year (median follow-up 53 months). Nitric oxide inhalation was used in 5 of the 27 cases, and it probably saved the life of 1 patient, may have helped in 1 case, and had no discernible effect in 3 cases. Severe pulmonary hypertension was most common after correction of complete atrioventricular septal defects (14%, n = 12/85). Thirteen of 131 children with Down syndrome (9.9%) had severe pulmonary hypertension. CONCLUSION: Severe postoperative pulmonary hypertension occurred after 2% of the cardiac procedures and in most cases was managed successfully with conventional treatment and had a favorable postoperative outcome. The low incidence relative to previous reports may reflect the benefits of early correction and improved intraoperative and postoperative care.

Long-distance transports of newborn infants with congenital heart disease.

Little has been published about specific problems that may occur during long-distance transports of newborn cardiac patients. During a 4-year period after centralization of pediatric heart surgery in Sweden, 286 transports were prospectively investigated. A majority (77.3%) of the transports were carried out by nonspecialized teams. Ten severe adverse events, including the death of 1 infant, occurred during the 286 transports (3.5%). Another infant died later of cerebral complications from hypoxia, rendering a transport-related mortality of 0.7%. Twenty-two infants (7.7%) were severely hypoxic (oxygen saturation < or =65%) at arrival, and 12 of these infants suffered from transposition of the great arteries. During the second 2-year period increased use of intravenous prostaglandin E1 and transportation from tertiary-level units was associated with better transport outcome. During the same time period, overall 30-day postoperative mortality for pediatric cardiac surgery decreased from 4.0% to 1.2% in our hospital. When highly specialized treatment is centralized for quality reasons it is also important that risks associated with transport are considered and that the quality of transport is high. For some cardiac malformations antenatal diagnosis and referral of the mother for delivery to a center with pediatric cardiac surgery would probably further increase the chance of healthy survival in some infants.

The outcome of children born with pulmonary atresia and intact ventricular septum in Sweden from 1980 to 1999.

OBJECTIVE: To study the outcome of all children born with pulmonary atresia and intact ventricular septum in Sweden between 1980 and 1999. DESIGN: Retrospective study of medical records with review of the initial, preoperative angiocardiographic and echocardiographic examinations. RESULTS: A total of 84 children were born with pulmonary atresia and intact ventricular septum, giving an incidence of 4.2 per 100,000 live births. In all, 77 were operated on with a 1-year survival rate of 75%. Thirty-six children had ventriculocoronary communications, with a 1-year survival rate of 50%. At the end of the study period, 52 children were alive, 32 with biventricular repair, and 19 with univentricular repair. Follow-up time was 14 days-20 years (median, 6 years). Statistical analysis of incremental risk factors for death showed statistical significance for low birth weight, male sex, muscular pulmonary atresia, and having a systemic-to-pulmonary shunt as the sole initial intervention. CONCLUSION: Complete national data of all patients born with pulmonary atresia and intact ventricular septum during 1980-1999 in Sweden revealed a total mortality in accordance with previous reports for results for surgery. Further improvements demand a thorough preoperative investigation of the cardiac anatomy, particularly of the ventriculocoronary communications, to enable right ventricular decompression whenever possible.

Centralization of pediatric heart surgery in Sweden.

In Sweden, which has a population of 8.9 million people, pediatric heart surgery was previously performed in four cities. After a long, difficult process, centralization of pediatric heart surgery to two centers was achieved in 1993. The overall 30-day mortality for open-heart surgery on infants and children of 9.5% before the centralization (1988-1991) was reduced to 1.9% in 1995-1997. A causal relationship between the mortality rates before and after the centralization is impossible to prove. Heart surgery was concentrated to the two centers with the lowest surgical mortality, and the reduction in surgical mortality was observed over a short period of time which makes it likely that the centralization of the surgical activity promoted the improved results. During the later time period the amount of more complex surgery was clearly increased compared to that performed previously.

Early age at repair prevents restrictive right ventricular (RV) physiology after surgery for tetralogy of Fallot (TOF): diastolic RV function after TOF repair in infancy.

OBJECTIVES: To assess diastolic right ventricular (RV) physiology after tetralogy of Fallot repair in infancy. BACKGROUND: Restrictive RV physiology after tetralogy of Fallot repair is related to type of repair, pulmonary regurgitation, and late arrhythmias. METHODS: Forty-seven patients were investigated, 27 and 20 patients in Lund and London, respectively. Median age at repair was 0.78 years (0.08-0.99) and median follow-up was 3.0 years (0.08-10.4). Restrictive RV physiology was assessed by Doppler echocardiography. RESULTS: Thirteen patients (28%) had restrictive RV physiology at follow-up, three of 19 patients (16%) with transatrial repair and 10 of 28 patients (32%) with transventricular repair, respectively (p=0.1). Ten percent of the patients repaired before 6 months of age were restrictive at follow-up, increasing to 38% with repair after 9 months. Transannular patch (TAP) repair was performed in 55% of the patients, including eight of 10 patients (80%) with repair before 6 months of age. Thirty-one percent of the patients with TAP repair were restrictive. These restrictive patients had more severe preoperative pulmonary stenosis (p < 0.05), were older at repair (p < 0.05), and had shorter duration of pulmonary regurgitation (p < 0.001) at follow-up. CONCLUSIONS: Restrictive RV physiology is inversely related to age at repair and independent of type of outflow tract repair. Since TAP repair is more common in early repair, and restriction seems to be less frequent, long-term follow-up to assess adverse effects of pulmonary regurgitation is mandatory.

Serum S-100 protein levels after pediatric cardiac operations: a possible new marker for postperfusion cerebral injury.

BACKGROUND: The release of neuron-specific astroglial S-100 protein to the cerebrospinal fluid is a marker of cerebral damage. The aim of this study was to determine the pattern of release of S-100 protein to serum after pediatric cardiac operations and extracorporeal circulation. METHODS: Sequential blood samples from 97 children (up to 16 years) were taken after induction of anesthesia, immediately after the discontinuation of extracorporeal circulation, and 5 and 15 hours after extracorporeal circulation. The children were divided into five groups including three age groups, children with Mb Down syndrome, and children undergoing circulatory arrest. RESULTS: The serum concentrations of S-100 protein before the cardiac operation were found to be highest in neonates. Children with Down syndrome, regardless of age, had basal levels comparable to those in neonates. There was an increase in S-100 protein concentration immediately after extracorporeal circulation and a multivariate regression analysis showed this difference in S-100 protein concentration to be significant with respect to age (p = 0.002), perfusion time (p < 0.001), and circulatory arrest (p < 0.001), but the difference was not significant with respect to weight, Down syndrome, and core temperature (p > 0.8). In children younger than 1 month old and after circulatory arrest, levels of S-100 protein remained high at 5 hours after extracorporeal circulation. CONCLUSION: These findings emphasize the necessity of using age-matched reference values and taking perfusion time into consideration when S-100 protein levels are evaluated with respect to cerebral postperfusion injuries in pediatric patients undergoing cardiac operations.

Successful thrombolysis of an occluded modified Blalock shunt three days after operation.

A 10-day-old boy with pulmonary atresia received a right-sided aortopulmonary polytetrafluoroethylene shunt. Three days after the operation he became cyanotic and was reintubated. Shunt occlusion was confirmed with angiography. Recombinant tissue plasminogen activator was given locally into the proximal end of the shunt. The thrombus was completely resolved after 2 days. When administration of recombinant tissue plasminogen activator was stopped, heparin infusion was started for 5 days. Shunt patency was demonstrated by angiography at 3 months postoperatively.

Hemodynamic effects of tracheal and intravenous adrenaline in infants with congenital heart anomalies.

BACKGROUND: If intravenous access cannot be accomplished during cardiopulmonary resuscitation in children, tracheal administration of 100 micrograms/kg of adrenaline (ten times greater than the intravenous dose) is recommended. METHODS: In a randomized crossover study we recoreded the hemodynamic effect of a low dose of intravenous adrenaline and a ten times greater tracheal dose. While anesthetized for open heart surgery, fourteen infants received one dose of adrenaline intravenously (0.3 microgram/kg) and the other tracheally (3 micrograms/kg). RESULTS: During the first 5 minutes after administration mean arterial pressure (MAP) and heart rate (HR) increased after both intravenous and tracheal administration (P < 0.001). The maximum increase in MAP was 28% (17-68%, median and range) after intravenous injection and 20% (6-69%, P < 0.05 when compared to intravenous injection) after tracheal instillation. In four infants, MAP increased less than 10% after tracheal instillation. The maximum increases in MAP and HR occurred 1 min (1-2 min) after intravenous injection and 3 min (2-4 min) after tracheal instillation (P < 0.001). CONCLUSION: Tracheal administration 3 micrograms/kg adrenaline increased mean arterial blood pressure in infants with congenital cardiac anomalies, but the increase occurred later and was less consistent than after 0.3 microgram/kg of adrenaline given intravenously.

Ventilatory consequences of the lateral position and thoracotomy in children.

Functional residual capacity (FRC), breath-by-breath compliance of the respiratory system (Crs) and arterial oxygen tension (PaO2) were measured in ten children, two months to nine years of age, during anaesthesia for surgical correction of patent ductus arteriosus or coarctation of the aorta. The children were mechanically ventilated with halothane, nitrous oxide and oxygen. FIO2 was kept constant in each child. After induction of anaesthesia, FRC was 17 +/- 7 ml X kg-1 (mean +/- 1 SD), corresponding to 60 +/- 22 per cent of a predicted awake value. FRC increased to 21 +/- 8 ml X kg-1 (p = 0.0005) when the child was turned to its right side and decreased to 13 +/- 5 ml X kg-1 (p = 0.0003) when the pleura was opened. No significant change in Crs or PaO2 occurred during these manoeuvres. Retraction of the upper lung to visualize the great vessels caused a significant decrease in FRC, Crs, and PaO2. The lowest PaO2 observed during this stage was 70.0 mmHg. After surgery FRC and PaO2 were about the same as before surgery while Crs had decreased from 0.87 +/- 0.18 preoperatively to 0.64 +/- 0.15 ml X cmH2O-1 X kg-1 (p = 0.0069). This study shows that FRC increases when mechanically ventilated children are placed in the lateral position, and that thoracotomy is associated with marked changes in FRC, Crs and PaO2.

Increased alveolar deadspace after closure of cardiac septal defects: pulmonary air embolism or failure of homeostasis?

During surgery for closure of atrial or ventricular septal defects (ASD, VSD), we used a computerized on-line system to follow changes in the alveolar deadspace fraction. We observed a large increase in the alveolar deadspace immediately following septal defect closure. No increase had been observed post-cardio-pulmonary bypass in children operated upon because of aortic or pulmonary stenosis, or in adults undergoing myocardial revascularization. The increase in deadspace is probably a result of the lung's failure to adjust to the large decrease in pulmonary blood flow following septal defect closure. An alternative cause for the finding, that of pulmonary artery air embolism occurring intraoperatively, appears to be less likely.

Sinus of Valsalva aneurysm obstructing coronary arterial flow: case report and collective review of the literature.

One case of unruptured sinus of Valsalva aneurysm causing left coronary artery compression and lethal myocardial infarction in a 39-year old woman is described. In reviewing the literature, 15 previously published cases of sinus of Valsalva aneurysms disturbing coronary flow were found. It is concluded that the mechanism of coronary flow disturbance differs between aneurysms of the left and right sinuses, respectively. The rare congenital aneurysms of the left sinus carry a considerably greater risk of myocardial ischemia than those of the right sinus. The risk of this complication supports an aggressive surgical attitude towards asymptomatic sinus of Valsalva aneurysms.

Hemodynamic effects of sternum closure after open-heart surgery in infants and children.

Eight children (age 4 months - 9 years) were studied after surgical correction of congenital heart defects. Sternum closure reduced mean arterial pressure by 7% (p less than 0.05) and cardiac output by 14% (p less than 0.01), and increased central venous pressure by 2 mmHg (p less than 0.05). There was evidence of a decrease in intracardiac blood volume. It is suggested that the circulatory effects of sternum closure were due to increased pressure outside the heart, which reduced the pressure across the heart wall and the end-diastolic volume.

Surgical intervention in staphylococcal endocarditis.

Uncomplicated endocarditis is cured by medical treatment at a rate of 80% (75% 5-year survival rate). If incompensated, only 12% has shown to be curable without surgery. With valve replacement, on the other hand, the rate of success will be 80%. Of those surgically treated cases, less than 10% will develop recrudescent infection. Left heart vegetations predict the risk of congestive heart failure and/or embolism. It is assumed that 7-10 days of efficient antibiotic therapy without effect should lead to surgery. We have made valve replacement in six cases during recent years in staphylococcal endocarditis. The main indication for operation was congestive heart failure, and the valve used was the Björk-Shiley tilting disc. All patients had vegetations on the leaflets. One patient had a mitral insufficiency, and the other five had aortic insufficiency. Two cases were lost within four months after surgery. In general, indications for valve replacement are heart incompensation or vegetations on leaflets.

[Instrumental perforation of the intrathoracic oesophagus (author's transl)]. / Instrumentelle Perforation des intrathorakalen Osophagus. Erfolgreiche Behandlung einer 90jährigen Frau.

Due to a wide iatrogenic perforation of the oesophagus situated at the level of the carina a 90-year-old woman was admitted to hospital. Prompt recognition and immediate surgery were successful. The operation consisted of a right-sided thoracotomy, wide mediastinotomy, over-sewing of the perforation and pleural drainage. Oesophagostomy and gastrostomy were performed to relieve the oesophagus. A tube was inserted into the duodenum for artificial feeding. This method has been successful in previous cases.