Modified del Nido cardioplegia is associated with low incidence of low main strong ion difference and hyperchloremia in pediatric patients after cardiac surgery.

PURPOSE: The aims of this study were (1) to determine the associations of cardioplegic solutions with postoperative main strong ion difference (mSID), which is the difference between sodium ion concentration and chloride ion concentration ([Cl-]) and (2) to determine the associations of cardioplegic solutions with markers of organ dysfunction. METHODS: In this retrospective cohort study, patients aged <5 years who underwent cardiac surgery in a tertiary teaching hospital were included. Patients were classified on the basis of the type of cardioplegic solution: modified del Nido cardioplegia (mDNC) and conventional cardioplegia (CC). The effects of mDNC on postoperative mSID and markers of organ functions were examined using propensity-matched analysis. RESULTS: A total of 500 cases were included. mDNC solution was used in 163 patients (32.6%). After propensity score matching, patients in the mDNC group (n = 152) had significantly higher minimum mSID [28 (26, 30) mEq/L vs. 27 (25, 29) mEq/L, p = 0.02] and lower maximum [Cl-] [112 (109, 114) mEq/L vs. 113 (111, 117) mEq/L, p < 0.001] than patients in the CC group (n = 304). The incidences of low mSID and hyperchloremia in the mDNC group were significantly lower than those in the CC group (63.8 vs. 75.7%, p = 0.01 and 63.2 vs. 79.3%, p < 0.001, respectively). There was no significant difference in the incidence of postoperative acute kidney injury and B-type natriuretic peptide level between the two groups. CONCLUSION: The use of modified del Nido cardioplegia may reduce the incidence of abnormal mSID and hyperchloremia compared with the use of a chloride-rich cardioplegic solution.

General Anesthesia With Remimazolam During Minimally Invasive Cardiac Surgery for Atrial Septal Defect: A Pediatric Case Report.

Remimazolam is a new ultrashort-acting benzodiazepine sedative, the use of which has not been reported for pediatric cardiac surgery. This case report describes the use of remimazolam in a 6-year-old girl who underwent minimally invasive cardiac surgery with right-sided thoracotomy for an atrial septal defect. Under electroencephalographic monitoring, remimazolam (2-4 mg kg-1 h-1) and remifentanil (0.05 µg kg-1 min-1) were administered with an intercostal nerve block during the procedure. The patient awoke and was extubated promptly after surgery, without any serious adverse events, including intraoperative awareness. Remimazolam may be a viable option for general anesthesia during pediatric cardiac surgery.

Carboxyhemoglobin and Methemoglobin Levels and Hemolysis in Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass.

Hemolysis is a complication of cardiopulmonary bypass (CPB). Carboxyhemoglobin (COHb) and methemoglobin (MetHb) were suggested as potential hemolysis biomarkers. This retrospective study was based on a prospective registry aimed to determine the association of COHb and MetHb levels with hemolysis in pediatric patients <4 years old who underwent cardiac surgery with CPB. Plasma-free hemoglobin (PFH), COHb, and MetHb levels were measured before CPB; every 30 minutes during CPB; and on postoperative days 1, 2, and 3. Patients were classified into hemolysis and nonhemolysis groups based on the maximum PFH levels during CPB. A total of 193 patients were included. No significant difference was observed in the maximum COHb levels during CPB (COHb CPB ) between the hemolysis and nonhemolysis groups (1.2% [interquartile range {IQR} 0.9-1.4%] vs. 1.1% [IQR: 0.9-1.4%]; p = 0.17). The maximum MetHb levels during CPB (MetHb CPB ) were significantly higher in the hemolysis group than in the nonhemolysis group (1.3% [IQR: 1.1-1.5%] vs. 1.2% [IQR: 1.0-1.4%]; p = 0.007). Areas under the receiver operating curves of COHb CPB and MetHb CPB were 0.557 (95% confidence interval: 0.475-0.640) and 0.615 (95% confidence interval: 0.535-0.695), respectively. Therefore, the predictive ability of both hemolysis biomarkers during CPB is limited.

Associations of systemic oxygen consumption with age and body temperature under general anesthesia: retrospective cohort study.

BACKGROUND: Body temperature (BT) is thought to have associations with oxygen consumption (VO2). However, there have been few studies in which the association between systemic VO2 and BT in humans was investigated in a wide range of BTs. The aims of this study were 1) to determine the association between VO2 and age and 2) to determine the association between VO2 and BT. METHODS: This study was a retrospective study of patients who underwent surgery under general anesthesia at a tertiary teaching hospital. VO2 was measured by the Dräger Perseus A500 anesthesia workstation (Dräger Medical, Lubeck, Germany). The associations of VO2 with age and BT were examined using spline regression and multivariable regression analysis with a random effect. RESULTS: A total of 7,567 cases were included in this study. A linear spline with one knot shows that VO2 was reduced by 2.1 ml/kg/min with one year of age (p < 0.001) among patients less than 18 years of age and that there was no significant change in VO2 among patients 18 years of age or older (estimate: 0.014 ml/kg/min, p = 0.08). VO2 in all bands of BT < 36.0 °C was not significantly different from VO2 in BT > = 36 °C and < 36.5 °C. Multivariable linear regression analysis showed that compared with VO2 in BT > = 36 °C and < 36.5 °C as a reference, VO2 levels were significantly higher by 0.57 ml/kg/min in BT > = 36.5 °C and < 37 °C (p < 0.001), by 1.8 ml/kg/min in BT > = 37 °C and < 37.5 °C (p < 0.001), by 3.6 ml/kg/min in BT > = 37.5 °C and < 38 °C (p < 0.001), by 4.9 ml/kg/min in BT > = 38 °C and < 38.5 °C (p < 0.001), and by 5.7 ml/kg/min in BT > = 38.5 °C (p < 0.001). The associations between VO2 and BT were significantly different among categorized age groups (p = 0.03). CONCLUSIONS: VO2 increases in parallel with increase in body temperature in a hyperthermic state but remains constant in a hypothermic state. Neonates and infants, who have high VO2, may have a large systemic organ response in VO2 to change in BT.

Efficacy of prophylactic high-flow nasal cannula therapy for postoperative pulmonary complications after pediatric cardiac surgery: a prospective single-arm study.

PURPOSE: This study investigated the incidence of postoperative pulmonary complications (PPC) when high-flow nasal cannula therapy (HFNC) is used prophylactically after pediatric cardiac surgery, and evaluated its efficacy. METHODS: This was a single-arm prospective interventional study that was conducted in a tertiary teaching hospital with eight beds in the pediatric cardiac ICU after approval by the Ethics Committee. One-hundred children under the age of 48 months who were scheduled for cardiac surgery for congenital heart disease were recruited. HFNC was used for 24 h after extubation at a 2 L/kg/min flow rate. The primary outcome was the incidence of PPC within 48 h after extubation. PPC was defined as atelectasis and acute respiratory failure meeting certain criteria. We considered prophylactic HFNC as effective if the prevalence of PPC was < 10%, based on previous reports of reintubation rates of 6%-9% after pediatric cardiac surgery. RESULTS: A total of 91 patients were finally included in the analysis. The incidence of PPC within 48 h after extubation was 18.7%, whereas atelectasis was observed in 13.2%, and acute respiratory failure in 8.8%. Reintubation rate within 48 h after extubation was 0%. CONCLUSIONS: We found the incidence of PPC with prophylactic HFNC after planned extubation after pediatric cardiac surgery. However, the incidence was > 10%; therefore, we could not demonstrate its efficacy in this single-arm study. Further studies are needed to investigate whether the HFNC could be adapted as first-line oxygen therapy after pediatric cardiac surgery.

Regional Cerebral Oxygen Saturation and Estimated Oxygen Extraction Ratio as Predictive Markers of Major Adverse Events in Infants with Congenital Heart Disease.

Regional cerebral oxygen saturation (ScO2) determined by near-infrared spectroscopy, monitoring both arterial and venous blood oxygenation of the brain, could reflect the balance between oxygen delivery and consumption. The aim of this study was to determine the predictabilities of ScO2 and estimated oxygen extraction ratio (eO2ER) with outcomes in infants with congenital heart disease (CHD). This study was a two-center, retrospective study of patients at 12 months of age or younger with CHD who underwent cardiac surgery. The primary outcome was a composite of one or more major adverse events (MAEs) after surgery: death from any cause, circulatory collapse that needed cardiopulmonary resuscitation, and requirement for extracorporeal membrane oxygenation. Based on the assumptions of arterial to venous blood ratio, eO2ER was calculated. A total of 647 cases were included in this study. MAEs occurred in 16 patients (2.5%). There were significant differences in post-bypass ScO2 [46.61 (40.90, 52.05) vs. 58.52 (51.52, 66.08), p < 0.001] and post-bypass eO2ER [0.66 (0.60, 0.78) vs. 0.52 (0.43, 0.61), p < 0.001] between patients with MAEs and patients without MAEs. Area under the receiver operating curve (AUROC) of post-bypass ScO2 was 0.818 (95% confidence interval: 0.747-0.889), AUROC of post-bypass eO2ER was 0.783 (0.697-0.870) and AUROC of post-bypass maximum serum lactate level was 0.635 (0.525-0.746). Both ScO2 and eO2ER, especially after weaning off bypass, are acceptable predictive markers for predicting MAEs after cardiac surgery in infants.(227 words).

Outcomes associated with unrecognized acute kidney injury in postoperative pediatric cardiac patients.

BACKGROUND: The present retrospective study was carried out to determine the incidence of unrecognized cardiac surgery-associated acute kidney injury (CSA-AKI) due to infrequency of serum creatinine (SCr) measurements in pediatric cardiac patients and to assess the association between unrecognized CSA-AKI and clinical outcomes. METHODS: This study was a single-center, retrospective study of pediatric patients who underwent cardiac surgery. Patients were diagnosed with CSA-AKI based on SCr measurements, and unrecognized CSA-AKI was defined under the assumptions that there had been only one or two SCr measurements within 48 h after surgery: CSA-AKI unrecognized by one SCr measurement (AKI-URone), CSA-AKI unrecognized by two SCr measurements (AKI-URtwo), and CSA-AKI recognized by one and two SCr measurements (AKI-R). The change of SCr from baseline to postoperative day 30 (delta SCr30d) was assessed as a surrogate of kidney recovery. RESULTS: In a total of 557 cases, 313 patients (56.2%) were diagnosed with CSA-AKI, 188 (33.8%) of whom had unrecognized CSA-AKI. Delta SCr30d in the AKI-URtwo group and delta SCr30d in the AKI-URone group was not significantly different from delta SCr30d in the non-AKI group (p = 0.67 and p = 0.79, respectively). There were significant differences in the durations of mechanical ventilation, serum B-type natriuretic peptide levels, and lengths of stay in hospital between the non-AKI group and the AKI-URtwo group and between the non-AKI group and the AKI-URtwo group. CONCLUSIONS: Unrecognized CSA-AKI due to infrequent SCr measurements is not rare and is associated with prolonged mechanical ventilation, high postoperative BNP level, and prolonged length of stay in hospital. A higher resolution version of the Graphical abstract is available as Supplementary information.

An Assessment of the Practice of Neuromuscular Blockade and the Association Between Its Prophylactic Use and Outcomes Among Postoperative Pediatric Cardiac Patients.

OBJECTIVES: The authors investigated the management of neuromuscular blocking agents (NMBAs) for pediatric patients after cardiac surgery, and compared the outcomes of patients who received prophylactic NMBA (pNMBA) infusions and patients without pNMBA infusions. DESIGN: A retrospective cohort study. SETTING: At a tertiary teaching hospital. PARTICIPANTS: Patients younger than 18, with congenital heart disease, who underwent cardiac surgery. INTERVENTIONS: Commencement of NMBA infusion in the first 2 hours after surgery MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a composite of one or more of the following major adverse events (MAEs) that occurred within 7 days after surgery: death from any cause, a circulatory collapse that needed cardiopulmonary resuscitation, and requirement for extracorporeal membrane oxygenation. The secondary endpoints included the total duration of mechanical ventilation for the first 30 days after surgery. A total of 566 patients were included in this study. The MAEs occurred in 13 patients (2.3%). An NMBA was commenced within 2 hours after surgery in 207 patients (36.6%). There were significant differences in the incidence of postoperative MAEs between the pNMBA group and the non-pNMBA group (5.3% v 0.6%; p < 0.001). In multivariate regression models, pNMBA infusion was not significantly associated with the incidence of MAEs (odds ratio: 1.79, 95% CI: 0.23-13.93, p = 0.58), but was significantly associated with prolonged mechanical ventilation by 3.85 days (p < 0.001). CONCLUSIONS: Postoperative prophylactic neuromuscular blockade after cardiac surgery can be associated with prolonged mechanical ventilation, but has no association with MAEs among pediatric patients with congenital heart disease.

Anesthetic management of a patient with Osler-Weber-Rendu syndrome with multiple pulmonary arteriovenous malformations and pheochromocytoma for femoral artificial bone replacement: a case report.

BACKGROUND: Osler-Weber-Rendu syndrome is characterized by mucocutaneous telangiectasia and arteriovenous malformations in organs. Anesthesia for patients with Osler-Weber-Rendu syndrome is challenging due to complications and physiological changes. CASE PRESENTATION: The case was a 49-year-old female with Osler-Weber-Rendu syndrome, multiple pulmonary arteriovenous malformations and pheochromocytoma who presented for femoral bone head fracture with metastatic adenocarcinoma. The patient was scheduled to undergo bone tumor resection and artificial bone replacement, being positioned laterally with a planned operation duration of 5 h. Anesthesia was managed with spinal and epidural anesthesia, combined with sedation by sevoflurane using a supraglottic airway (SGA) device under spontaneous breathing. Her intraoperative and postoperative courses were uneventful. CONCLUSION: Neuraxial anesthesia combined with general anesthesia using an SGA device to maintain spontaneous ventilation in order to minimize the risk of rupture of pulmonary arteriovenous malformations could be an option.

Therapeutic plasma exchange in postpartum HELLP syndrome: a case report.

BACKGROUND: Postpartum hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is more difficult to treat than HELLP syndrome during pregnancy. We describe a case of postpartum HELLP syndrome that responded to plasma exchange (PE) therapy. CASE PRESENTATION: A 30-year-old primipara woman was hospitalized for gestational hypertension at 33 weeks of gestation and underwent an emergent cesarean section at 36 weeks and 6 days of gestation due to rapidly progressing pulmonary edema. After delivery, liver dysfunction and a rapid decrease in platelet count were observed, and the patient was diagnosed with severe HELLP syndrome. She experienced multiple organ failure despite intensive care, and PE therapy was initiated. Her general condition dramatically stabilized within a few hours of PE therapy. CONCLUSION: It is controversial whether PE therapy should be used primarily in the management of HELLP syndrome, but early initiation of PE therapy could be effective for severe HELLP syndrome.

Temporary hypotension and ventilation difficulty during endoscopic injection sclerotherapy for esophageal varices in a child with Fontan circulation: a case report.

BACKGROUND: Endoscopic procedures are rarely performed in children with congenital heart disease (CHD); therefore, the associated complications are unknown. We report an abrupt change in circulatory and respiratory condition during endoscopic injection sclerotherapy for esophageal varices. CASE PRESENTATION: A 9-year-old boy with a history of total anomalous pulmonary venous connection (TAPVC) repair and Fontan procedure for asplenia and a single ventricle with TAPVC underwent endoscopic injection sclerotherapy under general anesthesia for esophageal varices. Systolic blood pressure decreased from 70 to 50 mmHg following a sclerosant injection; a second injection reduced his peripheral oxygen saturation from 93 to 79% secondary to ventilation difficulty. Although we suspected anaphylaxis intraoperatively, postoperative imaging suggested that balloon dilation performed to prevent sclerosing agent leakage caused compression of the pulmonary venous chamber and trachea owing to the anomalous intrathoracic organ anatomy. CONCLUSION: Thorough understanding of the complex anatomy is important before performing endoscopic procedures in children with CHD to preoperatively anticipate possible intraoperative complications and select the optimal therapeutic approach and anesthesia management.

The frequency of postoperative BNP measurement and intervention threshold of BNP concentration in pediatric cardiac intensive care unit: a prospective multicenter observational study.

PURPOSE: The purpose of this study is to investigate the current status of postoperative BNP measurement in the pediatric cardiac intensive care unit (PCICU). METHODS: This was a prospective multicenter observational study. Children under 15 years old who underwent pediatric cardiac surgery were included. Postoperatively, all BNP measurement was collected in PCICU. We checked whether each BNP measurement was used for the decision-making of intervention or not. We divided the BNP measurements into 4 groups: group A 0-299 pg/ml (reference), group B 300-999 pg/ml, group C 1000-1999 pg/ml, group D ≧ 2000 pg/ml. We performed logistic regression analysis to compare the intervention ratio between group A and B, C, D. We also did multiple comparison analyses to compare the intervention ratio in each group. RESULTS: Thirty-nine (15.8%) measurements were used as a criterion to intervene in all BNP measurements. There was no protocol for the measurement of BNP in all institutions. The number of BNP measurements in each group is as follows: group A 113 (45.9%), group B 81 (32.9%), group C 45 (18.3%), group D 7 (2.8%). The intervention ratio in each group was 6.2% (group A), 8.6% (group B), 44.4% (group C), and 71.4% (group D). The intervention ratio of group C and D were significantly higher than group A: (Odds ratio (95%CI): 12.1(4.8-33.9), p < 0.0001, 25.2(5.2-146.2), p < 0.0001). The result of multiple comparisons is similar to logistic regression analysis. CONCLUSION: High BNP concentration, especially more than 1000 pg/ml, was more often intervened upon compared to that of less than 1000 pg/ml.

Intact survival from severe cardiogenic shock caused by the first attack of atrial tachycardia treated with extracorporeal membrane oxygenation and surgical left atrium appendage resection: a case report.

BACKGROUND: Atrial tachycardia (AT) is rare in children and can usually be reversed to sinus rhythm with pharmacotherapy and cardioversion. We report a rare case of severe left-sided heart failure due to refractory AT. CASE PRESENTATION: A 12-year-old boy had AT with a heart rate of 180 beats/minute, which was refractory to any medication and defibrillation despite the first attack. Due to rapid cardiorespiratory collapse shortly after arriving at our hospital, central extracorporeal membrane oxygenation (ECMO) with left arterial venting was started immediately. Although AT persisted after that, it stopped on the 3rd day after admission following surgical resection of the left atrial appendage thought to be the source of AT. He was weaned off ECMO on the 7th day and ventilator on the 14th day. CONCLUSIONS: The appropriate timing of central ECMO and surgical ablation were effective in saving this child from a life-threatening situation caused by refractory AT.

Preventative effects of bisoprolol transdermal patches on postoperative atrial fibrillation in high-risk patients undergoing non-cardiac surgery: A subanalysis of the MAMACARI study.

BACKGROUND: Perioperative atrial fibrillation (POAF) after non-cardiac surgery is a risk factor for cardiovascular events including stroke and death. The aim of this subanalysis of the MAMACARI study, a multicenter randomized control study on the effectiveness of a bisoprolol transdermal patch for prevention of perioperative myocardial injury in high-risk patients undergoing non-cardiac surgery, was to identify the predictors of POAF after non-cardiac surgery in high-risk patients and to determine changes in blood pressure and heart rate during bisoprolol patch administration in the perioperative period. METHODS AND RESULTS: Patients aged over 60 years with hypertension and a high revised cardiac risk index (≥2) who were scheduled to undergo non-cardiac surgery were randomly assigned to a bisoprolol patch group (n = 120) or a control group (n = 120). We divided the patients into two groups: patients with POAF (POAF group; n = 16) and patients without POAF (non-POAF group; n = 206). Multivariate analysis showed that bisoprolol patch therapy (OR: 0.30, 95% CI: 0.092-0.978) and surgery time of 250 min or more (OR: 4.99, 95% CI: 1.37-18.2) were independently associated with POAF. Although systolic blood pressure did not differ significantly between the two groups throughout the perioperative period, treatment with a bisoprolol patch significantly reduced heart rate throughout the perioperative period compared with that in the control group. CONCLUSIONS: Low dose of a bisoprolol patch in the perioperative period was effective for prevention of POAF after non-cardiac surgery in high-risk patients, while long surgery time was an independent risk factor for POAF. It is expected that low dose of a bisoprolol patch can prevent POAF without causing hypotension.

An Evaluation of the Safety and Feasibility of Adenosine-assisted Clipping Surgery for Unruptured Cerebral Aneurysms: Study Protocol.

The effectiveness of adenosine-induced flow arrest in surgical clipping for the cerebral aneurysms with difficulties in temporary clip placement to the proximal main trunk has been reported. This is the first clinical trial to evaluate the safety and feasibility of adenosine-assisted clipping surgery for unruptured cerebral aneurysms (UCAs) in Japan. The inclusion criteria are as follows: patients over 20 years old, patients who agree to be enrolled in this study after providing informed consent, patients who undergo clipping surgery for UCA in our institute, and patients in whom the surgeons (T.H. or I.D.) judge that decompression of the aneurysm is effective. The primary endpoint is a modified Rankin Scale (mRS) score 30 days after surgery. We plan to enroll 10 patients in this study. The original protocol of adenosine administration was established in this trial. Herein, we present the study protocol.

Higher preoperative Qp/Qs ratio is associated with lower preoperative regional cerebral oxygen saturation in children with ventricular septal defect.

PURPOSE: The relationship between regional cerebral oxygen saturation (rSO2) and the amount of left-to-right shunt in ventricular septal defect (VSD) patients has not yet been investigated. The purpose of this study was to identify the association of preoperative pulmonary to systemic blood flow (Qp/Qs) ratio and preoperative rSO2 in patients with VSD. METHODS: We retrospectively evaluated 49 VSD surgical closure candidates at a single institution. Preoperative Qp/Qs ratio was compared with rSO2 measurements at the time of VSD closure surgery. RESULTS: Forty-nine were eligible for the final analysis. The median age at surgery was 6 (interquartile range [IQR]: 3, 12) months, and 36.7% were male. Atrial septal defects coexisted in 51.0%. There were no genetic abnormalities except trisomy 21 in 32.6% of the patients. Pulmonary hypertension was found in 42.8%. The median Qp/Qs ratio, calculated based on catheter testing results before the surgery, was 2.7 (IQR: 2.1, 3.7). Postoperative rSO2 was significantly higher than preoperative values (52.2 ± 12.9, 63.5 ± 13.1%, p < 0.001). There was an inverse relationship of Qp/Qs and preoperative cerebral rSO2 (r = - 0.11, p = 0.02). CONCLUSION: A higher Qp/Qs ratio was associated with a lower preoperative cerebral rSO2 in pediatric patients with VSD.

Perioperative Milrinone Infusion Improves One-Year Survival After the Norwood-Sano Procedure.

OBJECTIVES: The aim of this study was to investigate whether milrinone infusion improved one-year survival in patients who underwent the Norwood-Sano procedure. DESIGN: A retrospective observational study. SETTING: A single-institution university hospital. PARTICIPANTS: Children who underwent the Norwood-Sano procedure from January 2008 to December 2014. INTERVENTIONS: Patients were categorized into two groups: group E+D, who received routine epinephrine and dopamine infusion, and group M, who received routine milrinone infusion for intra- and postoperative inotropic support. MEASUREMENTS AND MAIN RESULTS: The primary outcome of this study was one-year survival after the Norwood-Sano procedure. A total of 45 patients were included (group E+D, 22; group M, 23). One-year survival in group M was significantly higher than that in group E+D (95.7% [22/23] v 72.7% [16/22], p = 0.03). A Kaplan-Meier curve also showed that one-year survival in group M was significantly higher than that in group E+D (p = 0.04), from the result of the log-rank test. The number of patients who had any arrhythmias in the intensive care unit (ICU) was significantly lower in group M than in group E+D (21.7% [5/23] v 50% [11/22], p = 0.03). The duration of ICU stay did not have statistical difference between groups (group M 19; interquartile range [IQR], 15-28) v group E+D 19.5 (IQR, 16.3-35.5) days, p = 0.57). CONCLUSIONS: Perioperative milrinone infusion improved the mortality after the Norwood-Sano procedure. Potential advantages of milrinone compared with epinephrine are fewer arrhythmias and better systemic perfusion, which could decrease lethal cardiac events in the ICU.

Successful treatment with positive airway pressure ventilation for tension pneumopericardium after pericardiocentesis in a neonate: a case report.

BACKGROUND: Pneumopericardium in neonates is often associated with respiratory diseases, of which positive pressure ventilation (PPV) is an exacerbating factor. Here, we present a neonate case of pneumopericardium after cardiac surgery which was resolved after applying PPV. CASE PRESENTATION: A 28-day-old neonate with left recurrent nerve palsy after aortic reconstruction for interrupted aortic arch developed pericardial effusion. Pericardiocentesis was performed under general anesthesia, and a drainage tube was left in the pericardium. After extubation, stridor gradually exacerbated, following hemodynamic deterioration. A chest X-ray demonstrated pneumopericardium. Upper airway stenosis due to recurrent nerve palsy developed excessive negative pleural pressure, and air was drawn into pericardium via the insertion site of the drainage tube. After tracheal intubation and applying PPV, the pneumopericardium improved. CONCLUSION: PPV does not always exacerbate pneumopericardium. In a patient with pericardial-atmosphere communication, increased inspiration effort can cause pneumopericardium, and PPV is a therapeutic option to alleviate the pneumopericardium.

Evaluation of a point-of-care serum creatinine measurement device and the impact on diagnosis of acute kidney injury in pediatric cardiac patients: A retrospective, single center study.

BACKGROUND AND AIMS: Agreement between measurements of creatinine concentrations using point-of-care (POC) devices and measurements conducted in a standard central laboratory is unclear for pediatric patients. Our objectives were (a) to assess the agreement for pediatric patients and (b) to compare the incidence of postoperative acute kidney injury (AKI) according to the two methods. METHODS: This retrospective, single-center study included patients under 18 years of age who underwent cardiac surgery and who were admitted into the pediatric intensive care unit of a tertiary teaching hospital (Okayama University Hospital, Japan) from 2013 to 2017. The primary objective was to assess the correlation and the agreement between measurements of creatinine concentrations by a Radiometer blood gas analyzer (Cregas) and those conducted in a central laboratory (Crelab). The secondary objective was to compare the incidence of postoperative AKI between the two methods based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. RESULTS: We analyzed the results of 1404 paired creatinine measurements from 498 patients, whose median age was 14 months old (interquartile range [IQR] 3, 49). The Pearson correlation coefficient of Cregas vs Crelab was 0.968 (95% confidence interval [CI], 0.965-0.972, P < 0.001). The median bias between Cregas and Crelab was 0.02 (IQR -0.02, 0.05) mg/dL. While 199 patients (40.0%) were diagnosed as having postoperative AKI based on Crelab, 357 patients (71.7%) were diagnosed as having postoperative AKI based on Cregas (Kappa = 0.39, 95% CI, 0.33-0.46). In a subgroup analysis of patients whose Cregas and Crelab were measured within 1 hour, similar percentage of patients were diagnosed as having postoperative AKI based on Cregas and Crelab (42.8% vs 46.0%; Kappa = 0.76, 95% CI, 0.68-0.84). CONCLUSION: There was an excellent correlation between Cregas and Crelab in pediatric patients. Although more patients were diagnosed as having postoperative AKI based on Cregas than based on Crelab, paired measurements with a short time gap showed good agreement on AKI diagnosis.