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1.
Pediatr Crit Care Med ; 25(7 Suppl 1): e44-e52, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38959359

RESUMO

OBJECTIVES: To derive systematic-review informed, modified Delphi consensus regarding antifibrinolytic and adjunct hemostatic agents in neonates and children supported with extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE consensus conference. DATA SOURCES: A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION: Use of antifibrinolytics (epsilon-aminocaproic acid [EACA] or tranexamic acid), recombinant factor VII activated (rFVIIa), or topical hemostatic agents (THAs). DATA EXTRACTION: Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Eleven references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. MEASUREMENTS AND MAIN RESULTS: Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. One weak recommendation and three consensus statements are presented. CONCLUSIONS: Evidence supporting recommendations for administration of antifibrinolytics (EACA or tranexamic acid), rFVIIa, and THAs were sparse and inconclusive. Much work remains to determine effective and safe usage strategies.


Assuntos
Antifibrinolíticos , Técnica Delphi , Oxigenação por Membrana Extracorpórea , Hemostáticos , Ácido Tranexâmico , Humanos , Antifibrinolíticos/uso terapêutico , Antifibrinolíticos/administração & dosagem , Oxigenação por Membrana Extracorpórea/métodos , Criança , Hemostáticos/uso terapêutico , Hemostáticos/administração & dosagem , Ácido Tranexâmico/uso terapêutico , Ácido Tranexâmico/administração & dosagem , Fator VIIa/uso terapêutico , Fator VIIa/administração & dosagem , Proteínas Recombinantes/uso terapêutico , Proteínas Recombinantes/administração & dosagem , Recém-Nascido , Ácido Aminocaproico/uso terapêutico , Ácido Aminocaproico/administração & dosagem , Hemorragia/prevenção & controle , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Lactente , Consenso
2.
Pediatr Crit Care Med ; 25(7 Suppl 1): e7-e13, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38959355

RESUMO

OBJECTIVES: To derive systematic-review informed, modified Delphi consensus regarding the medications used for anticoagulation for pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE (PEACE). DATA SOURCES: A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION: Included studies assessed anticoagulation used in pediatric ECMO. DATA EXTRACTION: Two authors reviewed all citations independently, with a third reviewer adjudicating any conflicts. Eighteen references were used for data extraction as well as for creation of recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS: Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-informed recommendations and, when evidence was lacking, expert-based consensus statements, or good practice statements for anticoagulation during pediatric ECMO. A web-based modified Delphi process was used to build consensus via the Research and Development/University of California Appropriateness Method. Consensus was based on a modified Delphi process with agreement defined as greater than 80%. Two recommendations, two consensus statements, and one good practice statement were developed, and, in all, agreement greater than 80% was reached. CONCLUSIONS: There is insufficient evidence to formulate optimal anticoagulation therapy during pediatric ECMO. Additional high-quality research is needed to inform evidence-based practice for anticoagulation during pediatric ECMO.


Assuntos
Anticoagulantes , Técnica Delphi , Oxigenação por Membrana Extracorpórea , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Criança , Consenso
3.
Pediatr Crit Care Med ; 25(7): 643-675, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38959353

RESUMO

OBJECTIVES: To present recommendations and consensus statements with supporting literature for the clinical management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus conference. DATA SOURCES: Systematic review was performed using PubMed, Embase, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021, followed by serial meetings of international, interprofessional experts in the management ECMO for critically ill children. STUDY SELECTION: The management of ECMO anticoagulation for critically ill children. DATA EXTRACTION: Within each of eight subgroup, two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. DATA SYNTHESIS: A systematic review was conducted using MEDLINE, Embase, and Cochrane Library databases, from January 1988 to May 2021. Each panel developed evidence-based and, when evidence was insufficient, expert-based statements for the clinical management of anticoagulation for children supported with ECMO. These statements were reviewed and ratified by 48 PEACE experts. Consensus was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 23 recommendations, 52 expert consensus statements, and 16 good practice statements covering the management of ECMO anticoagulation in three broad categories: general care and monitoring; perioperative care; and nonprocedural bleeding or thrombosis. Gaps in knowledge and research priorities were identified, along with three research focused good practice statements. CONCLUSIONS: The 91 statements focused on clinical care will form the basis for standardization and future clinical trials.


Assuntos
Anticoagulantes , Estado Terminal , Oxigenação por Membrana Extracorpórea , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Anticoagulantes/uso terapêutico , Anticoagulantes/administração & dosagem , Criança , Estado Terminal/terapia , Recém-Nascido , Lactente , Pré-Escolar
4.
Curr Opin Pediatr ; 34(3): 255-260, 2022 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-35634698

RESUMO

PURPOSE OF REVIEW: This review summarizes the current literature surrounding the use of bivalirudin as an alternative anticoagulant for pediatric extracorporeal membrane oxygenation (ECMO) patients. RECENT FINDINGS: Recent single center studies describe that bivalirudin may be associated with decreased blood product transfusion, decreased cost and similar clinical outcomes for pediatric ECMO patients who have failed unfractionated heparin (UFH) anticoagulation. aPTT is the most common test to monitor bivalirudin but has several limitations. Other tests including dilute thrombin time (dTT) and viscoelastic assays are promising but more study is needed. Current evidence suggests that bivalirudin is a well tolerated and effective alternative anticoagulant for pediatric ECMO patients who have failed UFH anticoagulation but prospective studies are needed to confirm these results. SUMMARY: Bivalirudin is a promising alternative anticoagulant for pediatric ECMO patients who have failed UFH. Large prospective, multicenter studies are needed to confirm safety and efficacy.


Assuntos
Oxigenação por Membrana Extracorpórea , Anticoagulantes/efeitos adversos , Criança , Oxigenação por Membrana Extracorpórea/métodos , Heparina/efeitos adversos , Heparina/uso terapêutico , Hirudinas , Humanos , Fragmentos de Peptídeos , Estudos Prospectivos , Proteínas Recombinantes
5.
Pediatr Crit Care Med ; 21(11): 975-985, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32976347

RESUMO

OBJECTIVES: Objective of this study was to determine if bivalirudin resulted in less circuit interventions than unfractionated heparin. A secondary objective was to examine associations between bivalirudin dose and partial thromboplastin time, international normalized ratio, and activated clotting time. DESIGN: Prospective observational. SETTING: Medical-surgical and cardiac PICUs. PATIENTS: Neonatal and pediatric extracorporeal membrane oxygenation patients who received bivalirudin anticoagulation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twenty extracorporeal membrane oxygenation runs in 18 patients used bivalirudin; 90% were venoarterial. Median (interquartile range) age was 4.5 months (1.6-35 mo). Thirteen patients (72%) had an underlying cardiac diagnosis. Of the 20 runs using bivalirudin, 16 (80%) were initially started on unfractionated heparin and transitioned to bivalirudin due to ongoing circuit thrombosis despite therapeutic anti-Xa levels (n = 13), ongoing circuit thrombosis with unfractionated heparin greater than or equal to 40 U/kg/hr (n = 2), or absence of increase in ACT after bolus of 100 U/kg of unfractionated heparin and escalation of unfractionated heparin infusion (n = 1). Initial bivalirudin dose ranged from 0.2 to 0.5 mg/kg/hr; no bolus doses were used. Median (range) bivalirudin dose was 0.9 mg/kg/hr (0.15-1.6 mg/kg/hr). Median (interquartile range) time on extracorporeal membrane oxygenation was 226.5 hours (150.5-393.0 hr) including 84 hours (47-335 hr) on bivalirudin. Nonparametric results are as follows: the rate of circuit intervention was significantly lower in patients on bivalirudin than on unfractionated heparin (median [interquartile range]: 0 [0-1] and 1 [1-2], respectively; Wilcoxon p = 0.0126). Bivalirudin dose was correlated to PTT (rs = 0.4760; p < 0.0001), INR (rs = 0.6833; p < 0.0001), and ACT (rs = 0.6161; p < 0.0001). Four patients had a significant bleeding complication on bivalirudin. Survival to hospital discharge was 56%. CONCLUSIONS: Bivalirudin appears to be a viable option for systemic anticoagulation in pediatric extracorporeal membrane oxygenation patients who have failed unfractionated heparin, but questions remain namely its optimal monitoring strategy. This pilot study supports the need for larger prospective studies of bivalirudin in pediatric extracorporeal membrane oxygenation, particularly focusing on meaningful monitoring variables.


Assuntos
Oxigenação por Membrana Extracorpórea , Heparina , Anticoagulantes/efeitos adversos , Criança , Heparina/efeitos adversos , Hirudinas , Humanos , Fragmentos de Peptídeos , Projetos Piloto , Estudos Prospectivos , Proteínas Recombinantes , Estudos Retrospectivos
6.
Pediatr Radiol ; 48(10): 1488-1502, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30079444

RESUMO

Extracorporeal membrane oxygenation (ECMO) is a life-saving treatment for pediatric patients with respiratory and/or cardiac failure. The ECMO circuit oxygenates and sometimes pumps the blood, effectively replacing lung and/or heart function temporarily. ECMO patients are clinically very complex not only because of their underlying, life-threatening pathology, but also because of the many physiological parameters that must be monitored and adjusted to maintain adequate tissue perfusion and oxygenation. Drainage and reinfusion cannulae connecting the patient to the ECMO circuit are visible on radiograph. These cannulae have different functions, different configurations, different radiographic appearances, and different positions that should be familiar to the interpreting pediatric radiologist. The primary complications of ECMO include hemorrhage, thrombosis and ischemia, as well as equipment failure and cannula malpositioning, all of which may be detected on imaging. In this pictorial essay, we discuss the basics of ECMO function and clinical management, ECMO cannula features and configurations, and the many complications of ECMO from an imaging perspective. Our goal is to educate pediatric radiologists about ECMO imaging, equipping them to properly interpret these studies and to become a useful consultant in ECMO patient care.


Assuntos
Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca/terapia , Pediatria/métodos , Radiografia Torácica , Insuficiência Respiratória/terapia , Criança , Humanos
7.
Pediatr Crit Care Med ; 18(11): 1055-1062, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28922263

RESUMO

OBJECTIVES: A continuous infusion of unfractionated heparin is the most common anticoagulant used for pediatric patients on extracorporeal life support. The objective of this study was to compare extracorporeal life support complications and outcomes between two large-volume pediatric extracorporeal life support centers that use different anticoagulation strategies. DESIGN: Prospective, observational cohort study. SETTING: The University of Michigan used simple anticoagulation monitoring, whereas the University of Alberta used an intensive anticoagulation monitoring strategy. PATIENTS: Pediatric patients on extracorporeal life support. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was major bleeding per extracorporeal life support run defined as bleeding that was retroperitoneal, pulmonary, or involved the CNS; bleeding greater than 20 mL/kg over 24 hours; or bleeding that required surgical intervention. Secondary outcomes measured were patient thrombosis per run, circuit thrombosis per run, and survival to hospital discharge per patient. Eighty-eight patients (95 runs) less than 18 years old were enrolled at the two centers over 2 years. The two centers enrolled different extracorporeal life support populations; University of Alberta enrolled more postcardiac surgical patients (74% vs 47%; p = 0.005). The indication for extracorporeal life support support also varied by center (p = 0.04). The two centers used similar proportions of VA extracorporeal life support (p = 0.3). Median (interquartile range) unfractionated heparin doses were similar between University of Michigan and University of Alberta, 30 (21-34) U/kg/hr and 26 (22-31) U/kg/hr, p value equals to 0.3, respectively. Median (interquartile range) antifactor Xa was lower in the University of Michigan cohort (0.23 [0.19-0.28] vs 0.41 [0.36-0.46] U/mL; p < 0.001). There was no significant difference in major bleeding (15% University of Michigan vs 21% University of Alberta; p = 0.6) or in patient thromboses (18% University of Michigan vs 13% University of Alberta; p = 0.5). There was no significant difference in survival to hospital discharge (University of Michigan 63% vs University of Alberta 73%; p = 0.1). CONCLUSIONS: Although this prospective cohort study compared different pediatric extracorporeal life support populations, the results did not identify a significant difference in outcomes between simple and intensive anticoagulation monitoring strategies.


Assuntos
Anticoagulantes/efeitos adversos , Testes de Coagulação Sanguínea/métodos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Hemorragia/prevenção & controle , Heparina/efeitos adversos , Trombose/prevenção & controle , Adolescente , Anticoagulantes/uso terapêutico , Criança , Pré-Escolar , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Heparina/uso terapêutico , Humanos , Lactente , Recém-Nascido , Masculino , Monitorização Fisiológica , Estudos Prospectivos , Trombose/epidemiologia , Trombose/etiologia , Resultado do Tratamento
8.
Pediatr Crit Care Med ; 15(8): e340-6, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24901804

RESUMO

OBJECTIVE: To describe antithrombin levels, altered unfractionated heparin effect (anti-factor Xa activity and activated partial thromboplastin time), and adverse effects post administration of a single high dose of antithrombin concentrate. DESIGN: Retrospective review. PATIENTS: Infants and children with antithrombin levels less than 50% and a subtherapeutic unfractionated heparin effect. SETTING: Quaternary care children's hospital with a dedicated anticoagulation program. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A single high dose of antithrombin concentrate was administered. Antithrombin level, anti-factor Xa, and activated partial thromboplastin times were measured post antithrombin concentrate infusion and daily until stable. One hundred twenty-one patients received 246 doses of antithrombin. Patients were described using two cohorts based on the ability to obtain exact heparin doses. Cohort 1 included all patients between January 2004 and May 2008 when complete heparin dosing was unavailable. Cohort 2 included patients from May 2008 to May 2011 when heparin dose was available. Median age and weight were 3.7 months and 4.1 kg. Mean antithrombin concentrate dose was 222 IU/kg. Mean antithrombin level increased from 0.39 to 1.20 U/mL following antithrombin concentrate administration. In cohort 2, unfractionated heparin doses to achieve a target anti-factor Xa activity pre-post antithrombin concentrate were 28 and 19 U/kg/hr, respectively, for children 12 months old or younger and 25 and 19 U/kg/hr, respectively, for children older than 12 months. There were no hemorrhagic, thrombotic, or allergic events within 1 week of antithrombin concentrate administration. CONCLUSIONS: This is the largest study of antithrombin concentrate evaluation in children. Administration of antithrombin concentrate increases anti-factor Xa activity with lower administered unfractionated heparin doses.


Assuntos
Anticoagulantes/administração & dosagem , Antitrombinas/sangue , Inibidores do Fator Xa/sangue , Heparina/administração & dosagem , Anticoagulantes/efeitos adversos , Peso Corporal , Criança , Pré-Escolar , Feminino , Heparina/efeitos adversos , Humanos , Lactente , Recém-Nascido , Masculino , Tempo de Tromboplastina Parcial , Estudos Retrospectivos
9.
Pediatr Cardiol ; 34(1): 59-63, 2013 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-22644418

RESUMO

Heterotaxy syndrome (HS) is a complex disorder involving thoracic and abdominal asymmetries. Congenital heart disease is often accompanied by an intestinal rotation abnormality (IRA) that may predispose to bowel ischemia and infarction. There is controversy in the literature whether asymptomatic infants with HS must be screened for IRA and, if present, whether a prophylactic Ladd procedure should be performed. We performed a retrospective chart review of all patients who underwent a Ladd procedure from January 2007 to December 2010 at Stollery Children's Hospital, Edmonton, Canada. Twenty-nine patients underwent a Ladd procedure, 22 without HS but with symptomatic malrotation and 7 with HS and asymptomatic malrotation. Asymptomatic HS patients had a complication rate of 57 % after a prophylactic Ladd procedure compared with a complication rate of 9 % in the symptomatic non-HS population. The management of asymptomatic IRA in patients with HS remains controversial. We suggest that HS patients be screened for IRA and that asymptomatic patients be managed conservatively.


Assuntos
Síndrome de Heterotaxia/prevenção & controle , Volvo Intestinal/congênito , Criança , Pré-Escolar , Anormalidades do Sistema Digestório , Feminino , Humanos , Lactente , Recém-Nascido , Volvo Intestinal/cirurgia , Masculino , Estudos Retrospectivos , Resultado do Tratamento
10.
ASAIO J ; 68(3): 303-310, 2022 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-35080509

RESUMO

DISCLAIMER: These guidelines for adult and pediatric anticoagulation for extracorporeal membrane oxygenation are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing ECLS / ECMO and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.


Assuntos
Oxigenação por Membrana Extracorpórea , Adulto , Anticoagulantes/uso terapêutico , Criança , Consenso , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Humanos
11.
Pediatrics ; 149(1 Suppl 1): S39-S47, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34970677

RESUMO

CONTEXT: Cardiovascular dysfunction is associated with poor outcomes in critically ill children. OBJECTIVE: We aim to derive an evidence-informed, consensus-based definition of cardiovascular dysfunction in critically ill children. DATA SOURCES: Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020 using medical subject heading terms and text words to define concepts of cardiovascular dysfunction, pediatric critical illness, and outcomes of interest. STUDY SELECTION: Studies were included if they evaluated critically ill children with cardiovascular dysfunction and assessment and/or scoring tools to screen for cardiovascular dysfunction and assessed mortality, functional status, organ-specific, or other patient-centered outcomes. Studies of adults, premature infants (≤36 weeks gestational age), animals, reviews and/or commentaries, case series (sample size ≤10), and non-English-language studies were excluded. Studies of children with cyanotic congenital heart disease or cardiovascular dysfunction after cardiopulmonary bypass were excluded. DATA EXTRACTION: Data were abstracted from each eligible study into a standard data extraction form, along with risk-of-bias assessment by a task force member. RESULTS: Cardiovascular dysfunction was defined by 9 elements, including 4 which indicate severe cardiovascular dysfunction. Cardiopulmonary arrest (>5 minutes) or mechanical circulatory support independently define severe cardiovascular dysfunction, whereas tachycardia, hypotension, vasoactive-inotropic score, lactate, troponin I, central venous oxygen saturation, and echocardiographic estimation of left ventricular ejection fraction were included in any combination. There was expert agreement (>80%) on the definition. LIMITATIONS: All included studies were observational and many were retrospective. CONCLUSIONS: The Pediatric Organ Dysfunction Information Update Mandate panel propose this evidence-informed definition of cardiovascular dysfunction.


Assuntos
Doenças Cardiovasculares/diagnóstico , Insuficiência de Múltiplos Órgãos/diagnóstico , Doenças Cardiovasculares/fisiopatologia , Sistema Cardiovascular/fisiopatologia , Criança , Estado Terminal , Humanos , Insuficiência de Múltiplos Órgãos/fisiopatologia , Escores de Disfunção Orgânica
12.
Pediatr Crit Care Med ; 12(1): 57-60, 2011 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-20453705

RESUMO

OBJECTIVE: To describe the clinical course of a group of patients who received a rotating inotrope regimen, including levosimendan, for decompensated congestive heart failure. DESIGN: Case series. SETTING: Pediatric intensive care unit in a tertiary care children's hospital. PATIENTS: Nine pediatric patients with severe, decompensated heart failure. INTERVENTION: The study patients received a rotating inotrope regimen, including levosimendan, dobutamine, and, in some cases, milrinone. MEASUREMENTS AND MAIN RESULTS: Six patients were weaned from positive-pressure ventilation. Eight patients were discharged from the intensive care unit, and seven survived to hospital discharge. Two patients were successfully bridged to orthotopic cardiac transplantation. The therapies were generally well tolerated. CONCLUSIONS: Rotating inotropes were safe and seemed to be effective in this heterogeneous population of infants and children with decompensated heart failure. This therapeutic regimen warrants prospective comparative analysis.


Assuntos
Cardiotônicos/uso terapêutico , Dobutamina/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Hidrazonas/uso terapêutico , Milrinona/uso terapêutico , Piridazinas/uso terapêutico , Adolescente , Quimioterapia Combinada , Ecocardiografia , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Pediátrica , Masculino , Estudos Retrospectivos , Simendana , Resultado do Tratamento
13.
J Paediatr Child Health ; 46(12): 777-9, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-20500438

RESUMO

We present the clinical course and management of two infants with idiopathic infantile arterial calcification. Both had coronary artery involvement and presented with ischaemic cardiac failure. Neither responded well to conventional therapy with inotropic agents, glyceryl trinitrate, diuretic and mechanical ventilation, nor to short-term biphosphonates. One was treated with levosimendan and extracorporeal membrane oxygenation to no avail.


Assuntos
Calcificação Vascular , Calcinose/diagnóstico , Calcinose/diagnóstico por imagem , Calcinose/tratamento farmacológico , Calcinose/fisiopatologia , Evolução Fatal , Feminino , Insuficiência Cardíaca/etiologia , Humanos , Recém-Nascido , Radiografia , Ultrassonografia , Doenças Vasculares/diagnóstico , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/tratamento farmacológico , Doenças Vasculares/fisiopatologia
14.
Pediatrics ; 142(2)2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30049892

RESUMO

BACKGROUND: Infants with heterotaxy syndrome (HS) have abnormal lateralization of organs along the right-left body axis. Intestinal rotation abnormalities (IRAs) are a potential source of morbidity and mortality. For this study, our objective was to prospectively observe a cohort of infants with HS and determine the incidence and natural history of IRA. METHODS: Infants ≤6 months of age with HS were enrolled in this prospective observational study. Exclusion criteria were other congenital abnormalities that necessitated abdominal surgery. HS was defined as any arrangement of organs that was not situs solitus or situs inversus along with associated congenital heart disease. The investigation for IRA was at the discretion of each participating center. RESULTS: Infants were recruited from January 2012 to December 2016. Thirty-eight infants from 7 institutions were included; 22 infants had right isomerism and 16 infants had left isomerism. Twenty-nine infants (76%) were evaluated for IRAs; 21 of 29 evaluations (72%) were abnormal. Eight infants were investigated because of symptoms, and 21 infants were evaluated routinely. The median age at symptom presentation was 46 days (range: 5-171 days). Seven infants had a Ladd procedure; 4 were prophylactic, with 3 as part of a combined procedure, and 3 were emergent. No child suffered acute midgut volvulus over a median follow-up of 1.6 years (range: 0.06-4.93 years). CONCLUSIONS: IRAs are common in infants with HS. Infants with symptoms presented by 6 months of age. There was no failure of expectant management resulting in midgut volvulus during a median follow-up of 1.6 years.


Assuntos
Síndrome de Heterotaxia/diagnóstico , Síndrome de Heterotaxia/epidemiologia , Volvo Intestinal/diagnóstico , Volvo Intestinal/epidemiologia , Pré-Escolar , Estudos de Coortes , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Prospectivos , Rotação/efeitos adversos
15.
World J Pediatr Congenit Heart Surg ; 8(3): 414-416, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-27143718

RESUMO

A term neonate was cannulated for venoarterial extracorporeal life support (ECLS) via the right neck for non-postoperative junctional ectopic tachycardia. Initial echocardiogram demonstrated an echogenic strand in the transverse arch. Computed tomography angiogram confirmed arterial dissection of the right common carotid artery that extended into the proximal transverse arch. Dissection flap was repaired at the time of ECLS decannulation without cardiopulmonary bypass. Follow-up computed tomography angiogram revealed a segment of narrowing of approximately 50% of the right common carotid artery without false lumen or aneurysm.


Assuntos
Dissecção Aórtica/etiologia , Artéria Carótida Primitiva , Cateterismo Venoso Central/efeitos adversos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Dissecção Aórtica/diagnóstico , Ecocardiografia , Feminino , Humanos , Recém-Nascido , Tomografia Computadorizada por Raios X
16.
ASAIO J ; 63(4): 456-463, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28557863

RESUMO

The purpose of this report is to describe the international growth, outcomes, complications, and technology used in pediatric extracorporeal life support (ECLS) from 2009 to 2015 as reported by participating centers in the Extracorporeal Life Support Organization (ELSO). To date, there are 59,969 children who have received ECLS in the ELSO Registry; among those, 21,907 received ECLS since 2009 with an overall survival to hospital discharge rate of 61%. In 2009, 2,409 ECLS cases were performed at 157 centers. By 2015, that number grew to 2,992 cases in 227 centers, reflecting a 24% increase in patients and 55% growth in centers. ECLS delivered to neonates (0-28 days) for respiratory support was the largest subcategory of ECLS among children <18-years old. Overall, 48% of ECLS was delivered for respiratory support and 52% was for cardiac support or extracorporeal life support to support cardiopulmonary resuscitation (ECPR). During the study period, over half of children were supported on ECLS with centrifugal pumps (51%) and polymethylpentene oxygenators (52%). Adverse events including neurologic events were common during ECLS, a fact that underscores the opportunity and need to promote quality improvement work.


Assuntos
Oxigenação por Membrana Extracorpórea , Sistema de Registros , Adolescente , Reanimação Cardiopulmonar , Criança , Pré-Escolar , Oxigenação por Membrana Extracorpórea/efeitos adversos , Humanos , Lactente , Recém-Nascido
17.
Can J Cardiol ; 22(3): 217-20, 2006 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-16520852

RESUMO

OBJECTIVES: The present study determined the prevalence of dilated cardiomyopathy together with prolonged corrected QT (QTc) intervals in children. The study also examined whether an association exists between prolonged QTc intervals and ventricular dysrhythmia in a patient cohort with dilated cardiomyopathy. BACKGROUND: The morbidity and mortality for pediatric patients with dilated cardiomyopathy remains high and is a clinical challenge. The patient population includes a significant number of Hutterite patients with metabolic disease associated with dilated cardiomyopathy. METHODS: Thirty-eight pediatric patients with dilated cardiomyopathy were reviewed for the presence of prolonged QTc and dysrhythmias. Eleven patients had a metabolic etiology for their dilated cardiomyopathy. RESULTS: Thirty-six per cent of the patient cohort had a long QTc interval. After 50 months of follow-up, the probability of survival for a child with a long QTc interval was approximately 50%. The probability of survival for a child with a normal QTc interval was 72%. Seventy per cent of the patients who died had a metabolic etiology for their dilated cardiomyopathy and a long QTc. CONCLUSIONS: Dilated cardiomyopathy may be associated with a prolonged QTc and may increase the patient's risk for sudden death. The presence of a metabolic etiology for dilated cardiomyopathy increases the risk of death.


Assuntos
Arritmias Cardíacas/epidemiologia , Cardiomiopatia Dilatada/epidemiologia , Cardiomiopatia Dilatada/metabolismo , Síndrome do QT Longo/epidemiologia , Adolescente , Alberta/epidemiologia , Arritmias Cardíacas/complicações , Arritmias Cardíacas/mortalidade , Cardiomiopatia Dilatada/complicações , Cardiomiopatia Dilatada/mortalidade , Cardiomiopatia Dilatada/fisiopatologia , Criança , Pré-Escolar , Estudos de Coortes , Eletrocardiografia , Feminino , Humanos , Lactente , Recém-Nascido , Síndrome do QT Longo/etiologia , Síndrome do QT Longo/mortalidade , Síndrome do QT Longo/fisiopatologia , Masculino , Prontuários Médicos , Miocárdio/metabolismo , Prevalência , Estudos Retrospectivos , Taxa de Sobrevida
18.
Front Pediatr ; 4: 67, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27446890

RESUMO

Anticoagulation is an imperfect science and is even more complicated in neonates and young children. The addition of the extracorporeal life support (ECLS) foreign circuit adds an additional layer of complexity. Anticoagulation goals during ECLS are to maintain a clot-free circuit and a hemostatically balanced patient. Unfractionated heparin (UFH) is the default gold standard anticoagulant as no large studies have been performed on any other anticoagulants. This review will focus on the advantages and disadvantages of the various methods to monitor UFH anticoagulation, discuss alternative anticoagulants, and examine bleeding and thrombotic complications during ECLS.

19.
J Thorac Cardiovasc Surg ; 149(1): 222-8, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25218539

RESUMO

OBJECTIVE: Infants and children who undergo cardiopulmonary bypass and cardiac surgery are at risk of postoperative fluid overload. Peritoneal dialysis catheter (PDC) and peritoneal dialysis are reported to be effective means of postoperative fluid management. We sought to test the hypothesis that PDC insertion in the operating room at the time of Norwood palliation would decrease the time to achieve a negative fluid balance in a group of neonates with hypoplastic left heart syndrome. METHODS: A single center randomized controlled trial was performed. We randomized neonates with hypoplastic left heart syndrome to prophylactic PDC, with or without dialysis, or standard care (ie, no PDC). RESULTS: Twenty-two neonates were included; 10 were randomized to PDC and 12 were randomized to standard care. The mean time to first postoperative negative fluid balance was 2.70 ± 1.06 days for the prophylactic PDC group and 2.67 ± 0.65 days for the standard care group (P = .93). There was no difference between the 2 groups in time to lactate ≤ 2 mmol/L, maximum vasoactive-inotrope score on postoperative days 2 to 5, time to sternal closure, time to first extubation, modified clinical outcome score, or hospital length of stay. Twenty-one patients (95%) survived to hospital discharge. Four patients randomized to prophylactic PDC had 1 or more serious adverse events compared with no patients in the standard care group (P = .03). CONCLUSIONS: Prophylactic PDC, with or without dialysis, did not decrease the time to achieve a negative fluid balance after the Norwood procedure, did not alter physiological variables postoperatively, and was associated with more severe adverse events.


Assuntos
Cateteres de Demora , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Procedimentos de Norwood/efeitos adversos , Diálise Peritoneal/instrumentação , Equilíbrio Hidroeletrolítico , Desequilíbrio Hidroeletrolítico/terapia , Alberta , Desenho de Equipamento , Feminino , Mortalidade Hospitalar , Humanos , Síndrome do Coração Esquerdo Hipoplásico/diagnóstico , Síndrome do Coração Esquerdo Hipoplásico/mortalidade , Lactente , Mortalidade Infantil , Recém-Nascido , Tempo de Internação , Masculino , Procedimentos de Norwood/mortalidade , Cuidados Paliativos , Diálise Peritoneal/efeitos adversos , Diálise Peritoneal/mortalidade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Desequilíbrio Hidroeletrolítico/diagnóstico , Desequilíbrio Hidroeletrolítico/etiologia , Desequilíbrio Hidroeletrolítico/mortalidade , Desequilíbrio Hidroeletrolítico/fisiopatologia
20.
Circ Heart Fail ; 8(2): 312-21, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25575579

RESUMO

BACKGROUND: Survival after pediatric cardiac extracorporeal life support (ECLS) is guarded, and neurological morbidity varies widely. Our objective is to report our 10-year experience with cardiac ECLS, including survival and kindergarten entry neurocognitive outcomes; to identify predictors of mortality or adverse neurocognitive outcomes; and to compare 2 eras, before and after 2005. METHODS AND RESULTS: From 2000 to 2009, 98 children had venoarterial cardiac ECLS. Sixty-four patients (65%) survived to hospital discharge, and 50 (51%) survived ≤5 years of age. Neurocognitive follow-up of survivors was completed at mean (SD) age of 52.9 (8) months using Wechsler Preschool and Primary Scale of Intelligence. Logistic regression analysis found the longer time (hours) for lactate to fall below 2 mmol/L on ECLS (hazard ratio, 1.39; 95% confidence interval, 1.05, 1.84; P=0.022), and the amount of platelets (mL/kg) given in the first 48 hours (hazard ratio, 1.18; 95% confidence interval, 1.06, 1.32; P=0.002) was independently associated with higher in-hospital mortality. Receiving ECLS after the year 2005 was independently associated with lower risk of in-hospital mortality (hazard ratio, 0.36; 95% confidence interval, 0.13, 0.99; P=0.048). Extracorporeal cardiopulmonary resuscitation was not independently associated with mortality or neurocognitive outcomes. Era was not independently associated with neurocognitive outcomes. The full-scale intelligence quotient of survivors without chromosomal abnormalities was 79.7 (16.6) with 25% below 2 SD of the population mean. CONCLUSIONS: Mortality has improved over time; time for lactate to fall on ECLS and volume of platelets transfused are independent predictors of mortality. Extracorporeal cardiopulmonary resuscitation and era were not independently associated with neurocognitive outcomes.


Assuntos
Reanimação Cardiopulmonar/métodos , Transtornos Cognitivos/epidemiologia , Circulação Extracorpórea , Reanimação Cardiopulmonar/mortalidade , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Estimativa de Kaplan-Meier , Cuidados para Prolongar a Vida/métodos , Masculino
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