Intracranial Pressure and Cerebral Hemodynamics in Infants Before and After Glenn Procedure.

OBJECTIVES: This prospective cohort study aimed to investigate changes in intracranial pressure (ICP) and cerebral hemodynamics in infants with congenital heart disease undergoing the Glenn procedure, focusing on the relationship between superior vena cava pressure and estimated ICP. DESIGN: A single-center prospective cohort study. SETTING: The study was conducted in a cardiac center over 4 years (2019-2022). PATIENTS: Twenty-seven infants with congenital heart disease scheduled for the Glenn procedure were included in the study, and detailed patient demographics and primary diagnoses were recorded. INTERVENTIONS: Transcranial Doppler (TCD) ultrasound examinations were performed at three time points: baseline (preoperatively), postoperative while ventilated (within 24-48 hr), and at discharge. TCD parameters, blood pressure, and pulmonary artery pressure were measured. MEASUREMENTS AND MAIN RESULTS: TCD parameters included systolic flow velocity, diastolic flow velocity (dFV), mean flow velocity (mFV), pulsatility index (PI), and resistance index. Estimated ICP and cerebral perfusion pressure (CPP) were calculated using established formulas. There was a significant postoperative increase in estimated ICP from 11 mm Hg (interquartile range [IQR], 10-16 mm Hg) to 15 mm Hg (IQR, 12-21 mm Hg) postoperatively (p = 0.002) with a trend toward higher CPP from 22 mm Hg (IQR, 14-30 mm Hg) to 28 mm Hg (IQR, 22-38 mm Hg) postoperatively (p = 0.1). TCD indices reflected alterations in cerebral hemodynamics, including decreased dFV and mFV and increased PI. Intracranial hemodynamics while on positive airway pressure and after extubation were similar. CONCLUSIONS: Glenn procedure substantially increases estimated ICP while showing a trend toward higher CPP. These findings underscore the intricate interaction between venous pressure and cerebral hemodynamics in infants undergoing the Glenn procedure. They also highlight the remarkable complexity of cerebrovascular autoregulation in maintaining stable brain perfusion under these circumstances.

Ultrasound-guided post-pyloric feeding tube insertion in peri-operative cardiac infants.

Delivery of enteral nutrition in critical infants post-paediatric cardiac surgery is sometimes hampered, necessitating direct feeding into the small intestine. This study is highlighting the role of ultrasound-guided post-pyloric feeding tube insertion performed by the paediatric cardiac ICU intensivist in critically ill infants. METHODS: We carried out a prospective pilot observational experimental study in peri-operative cardiac infants with feeding intolerance between 2019 and 2021. Feeding tube insertion depends on a combination of ultrasound and gastric insufflation with air-saline mixture. Insertion was confirmed by bedside abdominal X-ray. RESULTS: Out of 500 peri-operative cardiac infants, 15 needed post-pyloric feeding tube insertion in median 15 postoperative day. All were under 6 months of age with average weight of 3 ± 0.2 kg. Median Risk Adjustment for Congenital Heart Surgery Categories was 4. Median insertion time was 15 minutes. No complications have been reported. First pass success rate was 87%, while a second successful insertion attempt was needed in 2 cases (13%). Target daily calorie intake was achieved within average of 3.5 ± 0.4 days. Mean post-pyloric feeding tube stay was 20 ± 3 days. Out of 15 infants, 3 patients died, 1 patient needed gastrostomy tube, and 11 patients were discharged home on oral feeds. CONCLUSIONS: Ultrasound-guided post-pyloric feeding tube insertion using gastric insufflation with air-saline mixture in peri-operative cardiac infants with feeding intolerance is a useful and practical bedside tool, and it can be performed by a trained paediatric cardiac ICU intensivist. It may have potential positive effects on morbidity and outcome.

Bedside ultrasonography screening for congenital renal anomalies in children with congenital heart diseases undergoing cardiac repair.

INTRODUCTION: Ultrasound (US) assessment of renal anomalies in children requiring pediatric cardiac surgery is not a standard practice. This study is highlighting the role of bedside US performed by intensivist to detect occult renal anomalies associated with congenital heart disease (CHD). METHODS: A cross sectional study for 100 consecutive children with CHD admitted to Pediatric Cardiac Intensive Care Unit (PCICU) in 2015. US of kidneys screening was performed by trained pediatric cardiac intensivists to ascertain the presence of both kidneys in renal fossae without gross anomalies and to investigate if early detection of occult kidney anomaly would have any impact on outcome. RESULTS: After screening of 100 consecutive children with CHD with renal US, we identified in 94 cases (94%) normal right and left kidney in the standard sonographer shape within the renal fossae. In 6 cases further investigation revealed ectopic kidney in 3 patients (50%), solitary functional kidney in 2 patients (33%) and bilateral grade IV hydronephrosis in one patient (17%). Urinary tract infection developed peri-operatively in 66% of the cases with kidney anomalies with statistical significance compared to patients with normal renal US (P: 0.0011). No significant renal impairment was noted in these patients post-surgery. We observed no specific association between the type of renal anomaly and specific CHD. CONCLUSION: Routine renal US in children with CHD demonstrated prevalence of associated congenital renal anomalies in 6% of children undergoing cardiac surgery. The presence of occult renal anomalies was associated with higher UTI risk. Performing routine renal US as a standard practice in children with CHD is justifiable.