Cerebral oxygenation during pediatric congenital cardiac surgery and its association with outcome: a retrospective observational study.

PURPOSE: Non-invasive cerebral oxygen saturation (ScO2) monitoring is an established tool in the intraoperative phase of pediatric congenital cardiac surgery (CCS). This study investigated the association between ScO2 and postoperative outcome by investigating both baseline ScO2 values and intraoperative desaturations from baseline. METHODS: All CCS procedures performed in the period 2010-2017 in our institution in which ScO2 was monitored were included in this historical cohort study. Baseline ScO2 was determined after tracheal intubation, before surgical incision. Subgroups were based on cardiac pathology and degree of intracardiac shunting. Poor outcome was defined based on length of stay (LOS) in the intensive care unit (ICU)/hospital, duration of mechanical ventilation (MV), and 30-day mortality. Intraoperatively, ScO2 total time below baseline (TBBL) and ScO2 time-weighted average (TWA) were calculated. RESULTS: Data from 565 patients were analyzed. Baseline ScO2 was significantly associated with LOS in ICU (odds ratio [OR] per percentage decrease in baseline ScO2, 0.95; 95% confidence interval [CI], 0.93 to 0.97; P < 0.001), with LOS in hospital (OR, 0.93; 95% CI, 0.91 to 0.96; P < 0.001), with MV duration (OR, 0.92; 95% CI, 0.90 to 0.95; P < 0.001) and with 30-day mortality (OR, 0.94; 95% CI, 0.91 to 0.98; P = 0.007). Cerebral oxygen saturation TWA had no associations, while ScO2 TBBL had only a small association with LOS in ICU (OR, 1.02; 95% CI, 1.01 to 1.03; P < 0.001), MV duration (OR,1.02; 95% CI, 1.01 to 1.03; P = 0.002), and LOS in hospital (OR, 1.02; 95% CI, 1.01 to 1.04; P < 0.001). CONCLUSION: In pediatric patients undergoing cardiac surgery, low baseline ScO2 values measured after tracheal intubation were associated with several adverse postoperative outcomes. In contrast, the severity of actual intraoperative cerebral desaturation was not associated with postoperative outcomes. Baseline ScO2 measured after tracheal intubation may help identify patients at increased perioperative risk.

RéSUMé: OBJECTIF: Le monitorage non invasif de la saturation cérébrale en oxygène (ScO2) est un outil bien établi en phase peropératoire de chirurgie cardiaque congénitale pédiatrique. Cette étude a examiné l'association entre la ScO2 et le pronostic postopératoire en étudiant les valeurs de ScO2 initiales et les désaturations peropératoires par rapport à ces valeurs. MéTHODE: Toutes les interventions en chirurgie cardiaque congénitale réalisées entre 2010 et 2017 dans notre établissement et au cours desquelles la ScO2 a été monitorée ont été incluses dans cette étude de cohorte historique. La ScO2 de base était déterminée après l'intubation trachéale, avant l'incision chirurgicale. Les sous-groupes ont été catégorisés en fonction de la pathologie cardiaque et des shunts intracardiaques. Un mauvais pronostic était défini en fonction de la durée de séjour à l'unité de soins intensifs (USI)/ l'hôpital, de la durée de ventilation mécanique et de la mortalité à 30 jours. Pendant l'intervention, le temps total pendant lequel la ScO2 était au-dessous des valeurs de base et la moyenne pondérée dans le temps ont été calculés. RéSULTATS: Les données de 565 patients ont été analysées. Une association significative a été observée entre la ScO2 de base et la durée de séjour à l'USI (diminution du rapport de cotes [RC] par pourcentage de la ScO2 de base, 0,95; intervalle de confiance [IC] 95 %, 0,93 à 0,97; P < 0,001), la durée de séjour à l'hôpital (RC, 0,93; IC 95 %, 0,91 à 0,96; P < 0,001), la durée de ventilation mécanique (RC, 0,92; IC 95 %, 0,90 à 0,95; P < 0,001) et la mortalité à 30 jours (RC, 0,94; IC 95 %, 0,91 à 0,98; P = 0,007). La moyenne pondérée dans le temps de la saturation cérébrale en oxygène n'a pas révélé d'association, alors que le temps total au-dessous des valeurs de base de ScO2 n'a révélé qu'une petite association avec la durée de séjour à l'USI (RC, 1,02; IC 95 %, 1,01 à 1,03; P < 0,001), la durée de ventilation mécanique (RC, 1,02; IC 95 %, 1,01 à 1,03; P = 0,002), et la durée de séjour à l'hôpital (RC, 1,02; IC 95 %, 1,01 à 1,04; P < 0,001). CONCLUSION: Chez les patients pédiatriques subissant une chirurgie cardiaque, des valeurs de ScO2 basses lorsque mesurées après l'intubation trachéale étaient associées à plusieurs complications postopératoires. En revanche, la gravité de la désaturation cérébrale peropératoire n'était pas associée aux devenirs postopératoires. La ScO2 de base mesurée après l'intubation trachéale pourrait nous aider à identifier les patients courant un risque périopératoire accru.

Onset of brain injury in infants with prenatally diagnosed congenital heart disease.

BACKGROUND: The exact onset of brain injury in infants with congenital heart disease (CHD) is unknown. Our aim was, therefore, to assess the association between prenatal Doppler flow patterns, postnatal cerebral oxygenation and short-term neurological outcome. METHODS: Prenatally, we measured pulsatility indices of the middle cerebral (MCA-PI) and umbilical artery (UA-PI) and calculated cerebroplacental ratio (CPR). After birth, cerebral oxygen saturation (rcSO2) and fractional tissue oxygen extraction (FTOE) were assessed during the first 3 days after birth, and during and for 24 hours after every surgical procedure within the first 3 months after birth. Neurological outcome was determined preoperatively and at 3 months of age by assessing general movements and calculating the Motor Optimality Score (MOS). RESULTS: Thirty-six infants were included. MOS at 3 months was associated with MCA-PI (rho 0.41, P = 0.04), UA-PI (rho -0.39, P = 0.047, and CPR (rho 0.50, P = 0.01). Infants with abnormal MOS had lower MCA-PI (P = 0.02) and CPR (P = 0.01) and higher UA-PI at the last measurement (P = 0.03) before birth. In infants with abnormal MOS, rcSO2 tended to be lower during the first 3 days after birth, and FTOE was significantly higher on the second day after birth (P = 0.04). Intraoperative and postoperative rcSO2 and FTOE were not associated with short-term neurological outcome. CONCLUSION: In infants with prenatally diagnosed CHD, the prenatal period may play an important role in developmental outcome. Additional research is needed to clarify the relationship between preoperative, intra-operative and postoperative cerebral oxygenation and developmental outcome in infants with prenatally diagnosed CHD.

Using extra systoles and the micro-fluid challenge to predict fluid responsiveness during cardiac surgery.

Fluid responsiveness prediction is difficult during cardiac surgery. The micro-fluid challenge (micro-FC; rapid central infusion of 50 ml) and the extrasystolic method utilising post-extrasystolic preload increases may predict fluid responsiveness. Two study windows during coronary artery bypass graft surgery were defined, 1: After anaesthesia induction until surgical incision, 2: Left internal mammarian artery surgical preparation period. Each window consisted of 10-15 min observation for extrasystoles before a micro-FC was performed, after which a traditional fluid challenge (FC) was performed (5 ml/kg). Extrasystolic and micro-FC induced changes in hemodynamic variables were derived as predictors of fluid responsiveness defined as stroke volume increasing > 10% following FC. 61 patients were studied. Post-ectopic changes in pulse pressure (PP) predicted fluid responsiveness with receiver operating characteristic area (AUC) of 0.69 [CI 0.40;0.97] in the first study window and 0.64 [0.44;0.86] in the second window. Other post-ectopic predictors such as pre-ejection period (PEP) and systolic blood pressure (SBP) had similar or lower AUCs. Heart rate was 52.9 (SD ±8.4) min- 1 and 53.6 (± 8.8) min- 1 in the two study windows. Micro-FC induced changes in PEP had AUC of 0.74 [0.57;0.90] in the first window and 0.60 [0.40;0.76] in the second window. Correcting micro-FC induced changes in PEP for the micro-FC induced changes in heart rate had AUCs of 0.84 [0.70;0.97] in the first window and 0.63 [0.47;0.79] in the second window. The investigated methods revealed insufficient validity during cardiac surgery. RR interval corrected changes during a micro-FC should be investigated further. Trial registration Clinicaltrials.gov: NCT03002129.