Comparison of hetastarch with albumin for postoperative volume expansion in children after cardiopulmonary bypass.

OBJECTIVE: Hetastarch has been studied as a volume expander in adults after cardiopulmonary bypass (CPB) and in recommended dosages has not altered coagulation studies or increased clinical bleeding. Hetastarch was compared with albumin in children after CPB to determine whether hetastarch use was associated with increased clinical bleeding or alteration of coagulation studies. DESIGN: Randomized double-blinded study. SETTING: University-affiliated children's hospital. PARTICIPANTS: Forty-seven children age 1 year or greater (mean 72.8 months; range 12 months to 15.5 years) scheduled for repair of congenital heart disease with moderate hypothermia were randomized to receive hetastarch or albumin as a postoperative volume expander during the first 24 hours after surgery. INTERVENTIONS: Thirty-eight children required colloid replacement therapy. Blood pressure, central venous pressure, urine output, and chest tube drainage were used to determine colloid requirement. MEASUREMENTS AND MAIN RESULTS: Clinical bleeding and laboratory studies of coagulation were evaluated as were requirements for colloid, crystalloid, and blood products. Twenty children received 6% hetastarch, and 18 received 5% albumin. No differences were found in the amount of replacement fluids required, or in coagulation parameters in children receiving 20 mL/kg or less of either colloid replacement therapy. An increase in prothrombin time was demonstrated in children who received greater than 20 mL/kg of 6% hetastarch (p = 0.006); however, no difference in clinical bleeding or blood product requirement was demonstrated between the hetastarch or albumin groups receiving more than 20 mL/kg. CONCLUSION: This study demonstrated that 6% hetastarch is safe and an effective plasma volume expander in the postoperative management of children, using volumes up to 20 mL/kg. Close laboratory monitoring and careful evaluation of clinical bleeding are suggested when larger doses of hetastarch are administered because of prolongation of the prothrombin time with more than 20 mL/kg of hetastarch.

Predicting outcome in pediatric submersion victims.

STUDY OBJECTIVE: To predict outcome in children after near-drowning. DESIGN: Retrospective cohort study. Vegetative state and death were classified as unfavorable outcomes, whereas all other outcomes were classified as favorable. Demographic, episode-related, clinical, laboratory, and treatment variables available at the time of admission were evaluated for their usefulness in predicting outcome. SETTING: Pediatric referral hospital. PARTICIPANTS: Children admitted after submersion injury in non-icy waters. RESULTS: The study cohort comprised 194 children (median age, 2.6 years; range, 5 months to 18 years); 131 were neurologically normal at the time of discharge, 10 had some degree of neurologic impairment, 15 were in a vegetative state at the time of discharge, and 38 died. We used a combination of partitioning and logistic regression to combine variables in a prediction rule that was always correct when unfavorable outcome was predicted. The final rule predicted favorable outcome for all children who were not comatose. Among comatose children, unfavorable outcome was predicted by a combination of absent pupillary light reflex, increased initial blood glucose concentration, and male sex. This rule had a specificity of 100%--children with favorable outcomes were always predicted to do well--and a sensitivity of 65%. Therefore the rule was overly optimistic for 35% of patients with unfavorable outcomes. CONCLUSION: Pediatric submersion victims can be assigned to high or low likelihoods of unfavorable outcome with the use of four variables: comatose state, lack of pupillary light reflex, sex, and initial blood glucose concentration. This prediction rule may be useful if it can be validated in another cohort.