Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline.

BACKGROUND: Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline. METHODS: A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus. RESULTS: 60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations. CONCLUSIONS: Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

Changes in Sedation Practices in Association with Delirium Screening in Infants After Cardiopulmonary Bypass.

Sedation in the cardiac intensive care unit (CICU) is necessary to keep critically ill infants safe and comfortable. However, long-term use of sedatives may be associated with adverse neurodevelopmental outcomes. We aimed to examine sedation practices in the CICU after the implementation of the Cornell Assessment of Pediatric Delirium (CAPD). We hypothesize the use of the CAPD would be associated with a decrease in sedative weans at CICU discharge. This is a single institution, retrospective cohort study. The study inclusion criteria were term infants, birthweight > 2.5 kg, cardiopulmonary bypass (CPB), and mechanical ventilation (MV) on postoperative day zero. During the study period, 50 and 35 patients respectively, met criteria pre- and post-implementation of CAPD screening. Our results showed a statistically significant increase in the incidence of sedative habituation wean at CICU discharge after CAPD implementation (24% vs. 45.7%, p = 0.036). There was a statistically significant increase in exposure to opiate (56% vs. 88.6%, p = 0.001) and dexmedetomidine infusions (52% vs 80%, p = 0.008), increased likelihood of clonidine use at CICU discharge (OR 9.25, CI 2.39-35.84), and increase in the duration of intravenous sedative infusions (8.1 days vs. 5.1 days, p = 0.04) No statistical difference was found in exposure to fentanyl (42% vs. 58.8%, p = 0.13) or midazolam infusions (22% vs. 25.7%, p = 0.691); and there was no change in benzodiazepine or opiate use at CICU discharge or dosage. The prevalence of delirium in the CAPD cohort was 92%. CAPD implementation in the CICU was associated with changes in sedation practices, specifically an increase in the use of dexmedetomidine, which possibly explains the increased clonidine weans at CICU discharge. This is the first report of the association between CAPD monitoring and changes in sedative practices. Multi-center prospective studies are recommended to evaluate sedative practices, delirium, and its effects on neurodevelopment.

Fumarate is a terminal electron acceptor in the mammalian electron transport chain.

For electrons to continuously enter and flow through the mitochondrial electron transport chain (ETC), they must ultimately land on a terminal electron acceptor (TEA), which is known to be oxygen in mammals. Paradoxically, we find that complex I and dihydroorotate dehydrogenase (DHODH) can still deposit electrons into the ETC when oxygen reduction is impeded. Cells lacking oxygen reduction accumulate ubiquinol, driving the succinate dehydrogenase (SDH) complex in reverse to enable electron deposition onto fumarate. Upon inhibition of oxygen reduction, fumarate reduction sustains DHODH and complex I activities. Mouse tissues display varying capacities to use fumarate as a TEA, most of which net reverse the SDH complex under hypoxia. Thus, we delineate a circuit of electron flow in the mammalian ETC that maintains mitochondrial functions under oxygen limitation.