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Background: Vascular rings represent 1% of congenital cardiovascular abnormalities. Phenotypic expression varies from asymptomatic to severe forms related to either oesophageal or tracheal compression. While refinement in prenatal screening led to an increase in fetal diagnosis, optimal management in asymptomatic neonates and infants is currently a matter of debate. We report our center experience of vascular ring management over three decades. Methods: In this single-center retrospective study, data were extracted from patient medical records. To obtain information on symptoms/medication at follow-up, clinical records from pediatric clinics were reviewed. For patients followed in other institutions, a web-based questionnaire was sent to referring pediatricians. Results: Out of 82 patients, 69 were symptomatic (84%). Common symptoms included recurrent respiratory tract infections (43%), stridor (32%), gastro-esophageal reflux (33%), and dysphagia (26%). Diagnosis relied on cardiac ultrasound, barium swallow studies, and chest computerized tomography scan. Surgical repair (thoracotomy 91%) was performed in 79 patients (96%). Median age at repair was 13 [interquartile range (IQR), 4.4-48] months. There was no mortality. Minor complications occurred in 14 patients (18%). Median hospital length of stay was 7 (IQR, 6-9) days. In total, 24% of patients remained symptomatic (median follow-up 54 months). Half of those were asthma-related, with nearly 90% freedom from ring-related symptoms. Conclusions: Most patients were symptomatic at the time of diagnosis. Vascular rings such as pulmonary slings or tracheal compression syndromes require prompt management. Despite surgery, 24% of patients were not symptom-free at follow-up. Finally, surgery in asymptomatic patients resulted in low morbidity supporting the current recommendation of early surgical repair. Level of Evidence: III.
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BACKGROUND: This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide. METHODS: An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022. RESULTS: 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers. CONCLUSIONS: Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.
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BACKGROUND: This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide. METHODS: An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022. RESULTS: 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers. CONCLUSIONS: Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.
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Ecocardiografía , Ecocardiografía Transesofágica , Atención Perioperativa , Encuestas y Cuestionarios , Cuidados IntraoperatoriosAsunto(s)
Procedimientos Quirúrgicos Cardíacos , Humanos , Estudios Prospectivos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Femenino , Masculino , Anciano , Estudios de Cohortes , Persona de Mediana Edad , Cognición , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/psicología , Complicaciones Posoperatorias/epidemiología , Delirio/etiología , Factores de TiempoRESUMEN
BACKGROUND: Impaired cognition is a major predisposing factor for postoperative delirium, but it is not systematically assessed. Anesthesia and surgery may cause postoperative delirium by affecting brain integrity. Neurofilament light in serum reflects axonal injury. Studies evaluating the perioperative course of neurofilament light in cardiac surgery have shown conflicting results. The authors hypothesized that postoperative serum neurofilament light values would be higher in delirious patients, and that baseline concentrations would be correlated with patients' cognitive status and would identify patients at risk of postoperative delirium. METHODS: This preplanned secondary analysis included 220 patients undergoing elective cardiac surgery with cardiopulmonary bypass. A preoperative cognitive z score was calculated after a neuropsychological evaluation. Quantification of serum neurofilament light was performed by the Simoa (Quanterix, USA) technique before anesthesia, 2 h after surgery, on postoperative days 1, 2, and 5. Postoperative delirium was assessed using the Confusion Assessment Method for Intensive Care Unit, the Confusion Assessment Method, and a chart review. RESULTS: A total of 65 of 220 (29.5%) patients developed postoperative delirium. Delirious patients were older (median [25th percentile, 75th percentile], 74 [64, 79] vs. 67 [59, 74] yr; P < 0.001) and had lower cognitive z scores (-0.52 ± 1.14 vs. 0.21 ± 0.84; P < 0.001). Postoperative neurofilament light concentrations increased in all patients up to day 5, but did not predict delirium when preoperative concentrations were considered. Baseline neurofilament light values were significantly higher in patients who experienced delirium. They were influenced by age, cognitive z score, renal function, and history of diabetes mellitus. Baselines values were significantly correlated with cognitive z scores (r, 0.49; P < 0.001) and were independently associated with delirium whenever the patient's cognitive status was not considered (hazard ratio, 3.34 [95% CI, 1.07 to 10.4]). CONCLUSIONS: Cardiac surgery is associated with axonal injury, because neurofilament light concentrations increased postoperatively in all patients. However, only baseline neurofilament light values predicted postoperative delirium. Baseline concentrations were correlated with poorer cognitive scores, and they independently predicted postoperative delirium whenever patient's cognitive status was undetermined.
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Procedimientos Quirúrgicos Cardíacos , Disfunción Cognitiva , Delirio , Delirio del Despertar , Humanos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Disfunción Cognitiva/etiología , Delirio/diagnóstico , Delirio/etiología , Delirio del Despertar/etiología , Filamentos Intermedios , Complicaciones Posoperatorias/etiología , Factores de Riesgo , Estudios ProspectivosRESUMEN
BACKGROUND: Postoperative delirium (POD) remains a frequent complication after cardiac surgery, with pre-operative cognitive status being one of the main predisposing factors. However, performing complete pre-operative neuropsychological testing is challenging. The magnitude of frontal electroencephalographic (EEG) α oscillations during general anaesthesia has been related to pre-operative cognition and could constitute a functional marker for brain vulnerability. OBJECTIVE: We hypothesised that features of intra-operative α-band activity could predict the occurrence of POD. DESIGN: Single-centre prospective observational study. SETTING: University hospital, from 15 May 2019 to 15 December 2021. PATIENTS: Adult patients undergoing elective cardiac surgery. MAIN OUTCOME MEASURES: Pre-operative cognitive status was assessed by neuropsychological tests and scored as a global z score. A 5-min EEG recording was obtained 30âmin after induction of anaesthesia. Anaesthesia was maintained with sevoflurane. Power and peak frequency in the α-band were extracted from the frequency spectra. POD was assessed using the Confusion Assessment Method for Intensive Care Unit, the Confusion Assessment Method and a chart review. RESULTS: Sixty-five (29.5%) of 220 patients developed POD. Delirious patients were significantly older with median [IQR] ages of 74 [64 to 79] years vs. 67 [59 to 74] years; P â<â0.001) and had lower pre-operative cognitive z scores (-0.52â±â1.14 vs. 0.21â±â0.84; P â<â0.001). Mean α power (-14.03â±â4.61âdB vs. -11.59â±â3.37âdB; P â<â0.001) and maximum α power (-11.36â±â5.28âdB vs. -8.85â±â3.90âdB; P â<â0.001) were significantly lower in delirious patients. Intra-operative mean α power was significantly associated with the probability of developing POD (adjusted odds ratio, 0.88; 95% confidence interval (CI), 0.81 to 0.96; P â=â0.007), independently of age and only whenever cognitive status was not considered. CONCLUSION: A lower intra-operative frontal α-band power is associated with a higher incidence of POD after cardiac surgery. Intra-operative measures of α power could constitute a means of identifying patients at risk of this complication. TRIAL REGISTRATION: NCT03706989.
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Procedimientos Quirúrgicos Cardíacos , Delirio , Delirio del Despertar , Adulto , Humanos , Delirio del Despertar/diagnóstico , Delirio del Despertar/epidemiología , Delirio del Despertar/etiología , Delirio/diagnóstico , Delirio/epidemiología , Delirio/etiología , Estudios Prospectivos , Electroencefalografía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Factores de RiesgoRESUMEN
BACKGROUND: Decline in olfaction may occur after general anesthesia, but the exact incidence and underlying physiopathology remain scarcely investigated. Olfactory dysfunction arises with aging and is known to be linked to cognitive impairment. In this pilot study, we evaluated the incidence of immediate postoperative decline in olfaction and its association with a preoperative cognitive test, performance at Clock Drawing Test (CDT), in a group of older patients. METHODS: This pilot study is a sub-analysis of a prospective observational study. Patients ≥ 65 years old and scheduled for elective non-cardiac surgery under sevoflurane-based anesthesia were enrolled. CDT was part of the preoperative evaluation. We assessed olfaction on the day before and the day after surgery (between 16 and 26 h postoperatively) using the Sniffin' Sticks 12-item identification test, which consists of pen-like devices displaying 12 different odors. Postoperative decline in olfaction was defined as a decrease of at least 1 standard deviation in the olfactory score. RESULTS: We included a total of 93 patients, among whom 19 (20.4%) presented a postoperative decline in olfaction. The incidence of postoperative decline in olfaction was higher in the "CDT low-score" (score ≤ 5/8) group (11/34, 32.4%) than in the "CDT high-score" (score ≥ 6/8) group (8/58, 13.6%) (P = 0.030). Despite adjusting for confounding variables, CDT score remained independently associated with immediate postoperative decline in olfactory identification function (OR 0.67, 95% CI 0.48 to 0.94, P = 0.022). CONCLUSIONS: Postoperative decline in olfaction occurred in 20.4% of older patients and was associated with poor preoperative performance at CDT. TRIAL REGISTRATION: This study was retrospectively registered on https://clinicaltrials.gov/ under the NCT04700891 number (principal investigator: Victoria Van Regemorter), in December 2020.
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Envejecimiento , Olfato , Humanos , Anciano , Proyectos Piloto , Anestesia General , Pruebas NeuropsicológicasAsunto(s)
Procedimientos Quirúrgicos Cardíacos , Humanos , Niño , Paro Cardíaco Inducido , Corazón , Soluciones Cardiopléjicas , Temperatura , MiocardioAsunto(s)
Antitrombinas , Procedimientos Quirúrgicos Cardíacos , Humanos , Niño , Antitrombina III , Anticoagulantes , CorazónRESUMEN
Children undergoing general anesthesia and surgery in the early years of life are exposed to the possible neurotoxicity of anesthetic agents. Prospective studies have shown deficits in behavior, executive function, social communication, and motor function in children undergoing anesthesia and surgery. Different biomarkers of neuronal injury have been evaluated neuronal injury in the pediatric population, among which neurofilaments represent a significant advantage as they are proteins exclusively expressed in neuronal tissue. Our aim was to evaluate the utility of serum neurofilament light (NfL) as a prognostic biomarker of neuronal injury in the pediatric population. A literature search was performed on PubMed, Embase, and Cochrane Databases in November 2022 for studies concerning serum NfL in the pediatric population in addition to a neurological assessment. Inclusion criteria were as follows: (1) prospective or retrospective studies, (2) studies including pediatric population until the age of 18 years, (3) serum NfL sampling, and (4) evaluation of neurological outcome. Data collection regarding study design, pediatric age, serum NfL levels, and results for neurological assessment were extracted from each study. Four manuscripts met the inclusion criteria and evaluated the prognostic utility of serum NfL in neonatal encephalopathy in correlation with the neurodevelopmental outcome that was assessed by the Bayley Scales of Infant Development until the age of 2 years. Children with neonatal encephalopathy showed significantly higher serum NfL vs. healthy controls and high serum NfL levels predicted an adverse neurological outcome. The decrease of serum NfL to a nadir point between 10 and 15 years old reflects the brain growth in healthy controls. No studies were available in the perioperative period. Conclusions: Serum NfL is a valuable biomarker in evaluating neuronal injury in the pediatric population. Further studies with perioperative serial sampling of serum NfL combined with standardized neurodevelopmental tests should be conducted to evaluate the neurotoxicity of anesthetic agents and monitor the effectiveness of specific neuroprotective strategies in pediatric patients undergoing anesthesia and surgery. What is Known: ⢠Preclinical animal data have shown neurotoxicity of the anesthetic agents in the developing brain. ⢠Data regarding anesthetic neurotoxicity in humans show limitations and no objective tools are available. What is New: ⢠This systematic review showed that serum NfL is a valuable biomarker of neuronal injury in the pediatric population. ⢠Perioperative use of serum NfL may be considered in future trials evaluating anesthetic neurotoxicity in the pediatric population and in monitoring neuroprotective strategies.
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Encefalopatías , Filamentos Intermedios , Adolescente , Animales , Niño , Preescolar , Humanos , Recién Nacido , Biomarcadores , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
BACKGROUND: Tissue oximetry devices use wavelengths in the 680-870 nm range to separate between oxygenated/deoxygenated hemoglobin. Conjugated bilirubin has an absorption peak at 730 nm. AIMS: We hypothesized that ForeSight Elite using 5 wavelengths reduces interference from bilirubin and shows higher regional tissue oxygen saturation (rSO2 ) than INVOS 5100C incorporating 2 wavelengths. METHODS: Infants and children undergoing living donor liver transplantation were included between March 2019 and September 2020. Cerebral and somatic rSO2 were measured, and real-time simultaneous data were collected. Additionally, measurements were collected at (1) baseline, (2) beginning of dissection phase, (3) beginning of anhepatic phase, (4) reperfusion phase, and (5) skin closure. Bilirubin level was available at baseline and at reperfusion. Hyperbilirubinemia was defined as bilirubin level ≥1.0 mg/dl. RESULTS: Thirty-three patients with median age of 27 months and median weight of 12 kg were included. Baseline bilirubin levels were higher compared to values at reperfusion (p = .021). A linear mixed effects model considering bilirubin as fixed and patient as random effect showed that there was a statistically significant difference in cerebral rSO2 readings in function of time (p = .031), device (p < .001), and bilirubin concentrations (p = .007) but not for hemoglobin (p = .347), SpO2 (p = .882), and arterial partial pressure of CO2 (Pa CO2 ) (p = .146). The model showed that there was a statistically significant difference in somatic rSO2 readings in function of device (p < .001) and bilirubin concentrations (p = .023) but not for time (p = .074), hemoglobin (p = .954), SpO2 (p = .108), and Pa CO2 (p = .775). Bland-Altman plot analyzing cerebral and somatic rSO2 between both devices showed respectively a mean absolute bias and 95% limits of agreement of 21.73% (-10.21 to 53.67) and 19.52% (-29.51 to 68.54). CONCLUSIONS: Oximetry devices emitting light at >2 wavelengths may overcome interference from hyperbilirubinemia providing higher rSO2 readings.
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Trasplante de Hígado , Donadores Vivos , Oximetría , Saturación de Oxígeno , Niño , Preescolar , Humanos , Lactante , Bilirrubina/análisis , Dióxido de Carbono/análisis , Hemoglobinas/análisis , Hiperbilirrubinemia , Oximetría/métodos , Oxígeno/análisisRESUMEN
Regional cerebral oxygen saturation (rS o2 ) obtained from near-infrared spectroscopy (NIRS) provides valuable information during cardiac surgery. The rS o2 is calculated from the proportion of oxygenated to total hemoglobin in the cerebral vasculature. Root O3 cerebral oximetry (Masimo) allows for individual identification of changes in total (ΔcHbi), oxygenated (Δ o2 Hbi), and deoxygenated (ΔHHbi) hemoglobin spectral absorptions. Variations in these parameters from baseline help identify the underlying mechanisms of cerebral desaturation. This case series represents the first preliminary description of Δ o2 Hbi, ΔHHbi, and ΔcHbi variations in 10 cardiac surgical settings. Hemoglobin spectral absorption changes can be classified according to 3 distinct variations of cerebral desaturation. Reduced cerebral oxygen content or increased cerebral metabolism without major blood flow changes is reflected by decreased Δ o2 Hbi, unchanged ΔcHbi, and increased ΔHHbi Reduced cerebral arterial blood flow is suggested by decreased Δ o2 Hbi and ΔcHbi, with variable ΔHHbi. Finally, acute cerebral congestion may be suspected with increased ΔHHbi and ΔcHbi with unchanged Δ o2 Hbi. Cerebral desaturation can also result from mixed mechanisms reflected by variable combination of those 3 patterns. Normal cerebral saturation can occur, where reduced cerebral oxygen content such as anemia is balanced by a reduction in cerebral oxygen consumption such as during hypothermia. A summative algorithm using rS o2 , Δ o2 Hbi, ΔHHbi, and ΔcHbi is proposed. Further explorations involving more patients should be performed to establish the potential role and limitations of monitoring hemoglobin spectral absorption signals.
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Procedimientos Quirúrgicos Cardíacos , Oxihemoglobinas , Humanos , Oximetría/métodos , Circulación Cerebrovascular/fisiología , Oxígeno , Hemoglobinas/metabolismoRESUMEN
OBJECTIVE: The use of brain function monitoring with processed electroencephalography (pEEG) during cardiac surgery is gaining interest for the optimization of hypnotic agent delivery during the maintenance of anesthesia. The authors sought to determine whether the routine use of pEEG-guided anesthesia is associated with a reduction of hemodynamic instability during cardiopulmonary bypass (CPB) separation and subsequently reduces vasoactive and inotropic requirements in the intensive care unit. DESIGN: This is a retrospective cohort study based on an existing database. SETTING: A single cardiac surgical center. PARTICIPANTS: Three hundred patients undergoing cardiac surgery, under CPB, between December 2013 and March 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred and fifty patients had pEEG-guided anesthesia, and 150 patients did not have a pEEG-guided anesthesia. Multiple logistic regression demonstrated that pEEG-guided anesthesia was not associated with a successful CPB separation (p = 0.12). However, the use of pEEG-guided anesthesia reduced by 57% the odds of being in a higher category for vasoactive inotropic score compared to patients without pEEG (odds ratio = 0.43; 95% confidence interval: 0.26-0.73; p = 0.002). Duration of mechanical ventilation, fluid balance, and blood losses were also reduced in the pEEG anesthesia-guided group (p < 0.003), but there were no differences in organ dysfunction duration and mortality. CONCLUSION: During cardiac surgery, pEEG-guided anesthesia allowed a reduction in the use of inotropic or vasoactive agents at arrival in the intensive care unit. However, it did not facilitate weaning from CPB compared to a group where pEEG was unavailable. A pEEG-guided anesthetic management could promote early vasopressor weaning after cardiac surgery.
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Procedimientos Quirúrgicos Cardíacos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Puente Cardiopulmonar , Electroencefalografía , Humanos , Estudios Retrospectivos , VasoconstrictoresRESUMEN
Abstract Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.
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Cuidados Críticos , AnestesiologíaRESUMEN
ABSTRACT: Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.
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Anestesia en Procedimientos Quirúrgicos Cardíacos , Cardiopatías Congénitas , Anestesiología , Atención PerioperativaRESUMEN
Levosimendan increasingly has been used to treat heart failure and cardiac dysfunction in pediatric patients. Currently, there is only limited evidence that this drug positively affects outcomes. The authors' aim was to investigate the effects of levosimendan on hemodynamic parameters and outcomes in pediatric patients in all clinical settings. The study design was a systematic review of randomized and nonrandomized studies. Randomized clinical trials (RCTs) were included in a meta-analysis. The primary outcome of the meta-analysis was the effect of levosimendan on central venous oxygen saturation (ScvO2) and lactate values as surrogate markers of low-cardiac-output syndrome. The study setting was any acute care setting. Study participants were pediatric patients (age <18 years) receiving levosimendan, and the intervention was levosimendan versus any control treatment. The authors identified 44 studies published from 2004 to 2020, including a total of 1,131 pediatric patients. Nine studies (enrolling 547 patients) were RCTs, all performed in a pediatric cardiac surgery setting. Three RCTs were judged to carry a low risk of bias. In the RCTs, levosimendan administration was associated with a significant improvement of ScvO2 (p = 0.03) and a trend toward lower postoperative lactate levels (p = 0.08). No differences could be found for secondary outcomes. Levosimendan use in pediatric patients is not associated with major side effects and may lead to hemodynamic improvement after cardiac surgery. However, its impact on major clinical outcomes remains to be determined. Overall, the quality of evidence for levosimendan use in pediatric patients is low, and further high-quality RCTs are needed.