Maternal obesity and excessive maternal weight gain during pregnancy: effects on outcomes after neonatal cardiac surgical procedures.

Introduction Maternal obesity is associated with an increased risk for adverse perinatal outcomes. Obesity is also associated with a chronic inflammatory state and metabolic derangements that affect the newborn. The additional use of cardiopulmonary bypass during the neonatal period could impact the systemic inflammatory response in the immediate postoperative period that manifests as cardiac depression and multi-organ dysfunction. This study aimed to determine the association of maternal obesity and excessive weight gain during pregnancy with the immediate postoperative morbidity of neonatal patients undergoing cardiopulmonary bypass. METHODS: A retrospective review of neonates who underwent cardiopulmonary bypass within the first 30 days of life at our institution between 2011 and 2013 was conducted. Postoperative variables investigated included the duration of length of mechanical ventilation, length of stay in the ICU, peak vasoactive inotrope scores, and peak lactate level. Maternal obesity was defined as 1st trimester body mass index ⩾30 kg/m2. Excessive weight gain was defined as ⩾12 kg gained during pregnancy. In order to determine the association between maternal obesity or excessive weight gain and postoperative variables, we used multiple linear regression, adjusting for birth weight and risk adjustment for congenital heart surgery score. RESULTS: Records from 58 mother-baby dyads were examined. After controlling for birth weight and risk adjustment for congenital heart surgery score, there were no significant associations between maternal obesity and excessive weight gain during pregnancy versus all postoperative outcomes measured. CONCLUSION: Despite the known negative impact of maternal obesity on perinatal outcomes, we were unable to find associations between maternal obesity and excessive weight gain during pregnancy versus postoperative outcomes.

Vancomycin-associated acute kidney injury in pediatric cardiac intensive care patients.

OBJECTIVE: Acute kidney injury (AKI) is a significant source of morbidity among critically ill pediatric patients, including those that have undergone cardiac surgery. Vancomycin may contribute to AKI in pediatric patients admitted to a cardiac intensive care unit. DESIGN AND SETTING: Patients admitted to the cardiac intensive care unit at Texas Children's Hospital and received vancomycin over a 4-year period were included in a case-control study. Patients were excluded if they underwent renal replacement therapy during vancomycin therapy. Patient demographic and disease state variables, vancomycin therapy variables, and use of other nephrotoxic medications were collected. The overall incidence of AKI was calculated based on doubling of serum creatinine during or within 72 hours of vancomycin therapy (vancomycin-associated AKI [vAKI]). Patients who developed vAKI were matched with three patients who did not develop vAKI, and conditional logistic regression was used to determine independent risk factors for vAKI. RESULTS: A total of 418 patients met study criteria (males 57.8%) and infants (31 days to 2 years) were the most populous age group (48.6%). Vancomycin-associated AKI occurred in 30 patients (7.2%), which resulted in a total of 120 patients (30 cases; 90 controls). No significant differences were noted in vancomycin dosing between groups. Vancomycin-associated AKI patients were less likely to have undergone cardiac surgery (P < .05), more likely to have undergone extracorporeal membrane oxygenation (P < .05), and had greater exposure to nephrotoxic medications (P < .05). A conditional logistic regression model identified extracorporeal membrane oxygenation as associated with vAKI (odds ratio 14.4, 95% confidence interval 1.02-203, P = .048) and patients with prior cardiovascular surgery (odds ratio 0.10, 95% confidence interval 0.02-0.51, P < .01) or an elevated baseline serum creatinine (odds ratio 0.009, 95% confidence interval 0.0002-0.29, P < .01) as less likely to develop vAKI. CONCLUSIONS: Vancomycin-associated AKI occurs infrequently in the pediatric cardiac intensive care population and is strongly associated with patient critical illness.

Does ICU structure impact patient outcomes after congenital heart surgery? A critical appraisal of "care models and associated outcomes in congenital heart surgery" by Burstein et al (Pediatrics 2011; 127: e1482-e1489).

OBJECTIVE: To review the findings and discuss the implications of different ICU care models on morbidity and mortality in pediatric patients after congenital heart surgery. DATA SOURCES: The electronic PubMed database was used to perform the clinical query, as well as to search for additional pertinent literature. STUDY SELECTION AND DATA EXTRACTION: The article by Burstein DS et al "Care Models and Associated Outcomes in Congenital Heart Surgery. Pediatrics 2011; 15:77-81" was selected for critical appraisal and literature review. DATA SYNTHESIS: The authors evaluated in-hospital mortality, postoperative length of stay, and postoperative complications in pediatric patients after congenital heart surgery and compared the odds of these outcomes by model of care received (cardiac ICU or mixed ICU). The data for the study was extracted from the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery (STS-EACTS) database. Overall, the cardiac ICU group represented hospitals with higher surgical volumes and included more patients with high-risk defects. After multivariate analysis, the adjusted in-hospital mortality was not associated with the care model (cardiac ICU vs. ICU). The only significant finding was a lower morality in the STS-EACTS risk category 3 (odds ratio, 0.47 [95% CI, 0.25-0.86]). There were no significant differences between groups for adjusted postoperative length of stay or postoperative complications. CONCLUSIONS: This paper suggests that the composition of the ICU is not a critical factor in determining outcomes after congenital heart surgery. Other factors, such as expertise of the nurses, physicians, and surgeons, as well as technical performance, should be considered.

An institutional experience with epidural analgesia in children and young adults undergoing cardiac surgery.

BACKGROUND: Allowing spontaneous respiration after cardiac surgery eliminates complications related to mechanical ventilation and optimizes cardiopulmonary interaction. Epidural analgesia has been proposed to promote early extubation after cardiac surgery. OBJECTIVE: To identify the characteristics of patients with epidural analgesia and safety profiles with respect to the timing of extubation following cardiac surgery. DESIGN AND METHOD: A retrospective chart review of patients who underwent cardiac surgery during a 5-year period. Demographic, procedural, and perioperative variables were analyzed to investigate factors that affect the timing of extubation. RESULTS: A total of 750 records were reviewed. The patients' median age was 12 months, and 52% were infants (<1 year). Seventy-five percent of the patients utilized cardiopulmonary bypass. The study population was classified into three groups according to the timing of extubation: 66% were extubated in the operating room or upon arrival at the PICU (Immediate), 15% were extubated within 24 h (mean, 10.8 h; 95% CI, 9.0-12.6) (Early), and 19% were extubated after 24 h (Delayed). For the Immediate and Early groups, multivariate logistic regression identified young age, increased cross-clamp time, and inotrope score as independent risk factors for the need for mechanical ventilation. Postextubation respiratory acidosis (mean P(a)CO(2), 50 mmHg; 95% CI, 49-51) was well tolerated by all patients. There were no neurologic complications related to the epidural technique. CONCLUSION: Epidural analgesia in children undergoing cardiac surgery provides stable analgesia without complications in our experience.

Tricuspid atresia and tetralogy of Fallot in an infant of a diabetic mother.

An infant of a diabetic mother with a prenatal diagnosis of tetralogy of Fallot and tricuspid atresia is presented. To the best of the authors' knowledge, this is the first report of such an association.