Prophylactic corticosteroids for paediatric heart surgery with cardiopulmonary bypass.

BACKGROUND: Corticosteroids are routinely given to children undergoing cardiac surgery with cardiopulmonary bypass (CPB) in an attempt to ameliorate the inflammatory response. Their use is still controversial and the decision to administer the intervention can vary by centre and/or by individual doctors within that centre. OBJECTIVES: This review is designed to assess the benefits and harms of prophylactic corticosteroids in children between birth and 18 years of age undergoing cardiac surgery with CPB. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and Conference Proceedings Citation Index-Science in June 2020. We also searched four clinical trials registers and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA: We included studies of prophylactic administration of corticosteroids, including single and multiple doses, and all types of corticosteroids administered via any route and at any time-point in the perioperative period. We excluded studies if steroids were administered therapeutically. We included individually randomised controlled trials (RCTs), with two or more groups (e.g. multi-drug or dose comparisons with a control group) but not 'head-to-head' trials without a placebo or a group that did not receive corticosteroids. We included studies in children, from birth up to 18 years of age, including preterm infants, undergoing cardiac surgery with the use of CPB. We also excluded studies in patients undergoing heart or lung transplantation, or both; studies in patients already receiving corticosteroids; in patients with abnormalities of the hypothalamic-pituitary-adrenal axis; and in patients given steroids at the time of cardiac surgery for indications other than cardiac surgery. DATA COLLECTION AND ANALYSIS: We used the Covidence systematic review manager to extract and manage data for the review. Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We resolved disagreements by consensus or by consultation with a third review author. We assessed the certainty of evidence with GRADE. MAIN RESULTS: We found 3748 studies, of which 888 were duplicate records. Two studies had the same clinical trial registration number, but reported different populations and interventions. We therefore included them as separate studies. We screened titles and abstracts of 2868 records and reviewed full text reports for 84 studies to determine eligibility. We extracted data for 13 studies. Pooled analyses are based on eight studies. We reported the remaining five studies narratively due to zero events for both intervention and placebo in the outcomes of interest. Therefore, the final meta-analysis included eight studies with a combined population of 478 participants. There was a low or unclear risk of bias across the domains. There was moderate certainty of evidence that corticosteroids do not change the risk of in-hospital mortality (five RCTs; 313 participants; risk ratio (RR) 0.83, 95% confidence interval (CI) 0.33 to 2.07) for children undergoing cardiac surgery with CPB. There was high certainty of evidence that corticosteroids reduce the duration of mechanical ventilation (six RCTs; 421 participants; mean difference (MD) 11.37 hours lower, 95% CI -20.29 to -2.45) after the surgery. There was high-certainty evidence that the intervention probably made little to no difference to the length of postoperative intensive care unit (ICU) stay (six RCTs; 421 participants; MD 0.28 days lower, 95% CI -0.79 to 0.24) and moderate-certainty evidence that the intervention probably made little to no difference to the length of the postoperative hospital stay (one RCT; 176 participants; mean length of stay 22 days; MD -0.70 days, 95% CI -2.62 to 1.22). There was moderate certainty of evidence for no effect of the intervention on all-cause mortality at the longest follow-up (five RCTs; 313 participants; RR 0.83, 95% CI 0.33 to 2.07) or cardiovascular mortality at the longest follow-up (three RCTs; 109 participants; RR 0.40, 95% CI 0.07 to 2.46). There was low certainty of evidence that corticosteroids probably make little to no difference to children separating from CPB (one RCT; 40 participants; RR 0.20, 95% CI 0.01 to 3.92). We were unable to report information regarding adverse events of the intervention due to the heterogeneity of reporting of outcomes. We downgraded the certainty of evidence for several reasons, including imprecision due to small sample sizes, a single study providing data for an individual outcome, the inclusion of both appreciable benefit and harm in the confidence interval, and publication bias. AUTHORS' CONCLUSIONS: Corticosteroids  probably do not change the risk of mortality for children having heart surgery using CPB at any time point. They probably reduce the duration of postoperative ventilation in this context, but have little or no effect on the total length of postoperative ICU stay or total postoperative hospital stay. There was inconsistency in the adverse event outcomes reported which, consequently, could not be pooled. It is therefore impossible to provide any implications and policy-makers will be unable to make any recommendations for practice without evidence about adverse effects. The review highlighted the need for well-conducted RCTs powered for clinical outcomes to confirm or refute the effect of corticosteroids versus placebo in children having cardiac surgery with CPB. A core outcome set for adverse event reporting in the paediatric major surgery and intensive care setting is required.

Derivación ventrículo-cava para hidrocefalia en casos extremos. Una alternativa viable / Ventriculocaval shunt for hydrocephalus in extreme cases. A viable alternative

Introducción. El manejo de la hidrocefalia habitualmente comprende la derivación del líquido cefalorraquídeo hacia alguna cavidad corporal. En circunstancias especiales, los pacientes requieren de abordajes alternos y el cirujano se enfrenta al empleo de opciones extremas. Caso clínico. En este estudio se presentan dos pacientes que se sometieron quirúrgicamente a una derivación ventrículo-cava a través de un acceso vascular periférico. Conclusiones. La técnica representó un abordaje de fácil aplicación y con mínimas complicaciones que nos brinda una opción de rescate en aquellos pacientes complicados. En los casos presentados, el empleo de esta técnica fue exitoso.

Background. Hydrocephalus management usually involves cerebrospinal fluid shunting into some corporal cavity. Under special circumstances, patients require alternate approaches, and the surgeon faces the use of extreme options. Case report. In this study we present two patients who were surgically approached with ventriculocaval shunt through peripheral vascular access. Conclusions. The technique represented an easy application with minimal complications, an approach that provides a rescue option in cases of complicated hydrocephalus. In our case, this technique was successful.

Experiencia en el cierre quirúrgico de ducto arterioso permeable en la Unidad de Cuidados Intensivos Neonatales (UCIN) de un hospital de segundo nivel en Guadalajara, Jalisco, México / Experience in the surgical closure of patent ductus arteriosus in the Neonatal Intensive Care Unit of a second-level hospital in Guadalajara, Jalisco, Mexico

Introducción. El ducto arterioso permeable (DAP) es la cardiopatía congénita más frecuente; afecta hasta el 80% de los recién nacidos pretérmino de extremado bajo peso al nacer (<1 000 g). Actualmente se considera un importante problema de salud pública. El objetivo de este trabajo es demostrar que es posible realizar cierre quirúrgico de DAP en pacientes prematuros, en un hospital de 2° nivel que cuente con un cirujano pediatra entrenado. Métodos. Se analizaron los antecedentes, evolución clínica y manejo quirúrgico de 31 pacientes con diagnóstico de DAP. Los criterios para cierre quirúrgico fueron: 1) fracaso al cierre farmacológico, 2) hipertensión pulmonar moderada a severa con flujo de izquierda a derecha, 3) ecocardiograma con conducto mayor de 1.5 mm y relación Qs/Qp mayor de 1.5:1, 4) más de 5 días de vida extrauterina con DAP-HS. El abordaje fue por toracotomía posterolateral izquierda con disección extrapleural y cierre del DAP con doble ligadura de seda 2-0. Resultados. Se estudiaron 31 pacientes, 19 masculinos y 12 femeninos. La edad varió entre 30 y 35 semanas de gestación; el peso osciló entre 1 y 1.5 kg. El ecocardiograma confirmó el diagnóstico en el 100% de los pacientes. Todos se operaron entre 7 y 10 días de vida extrauterina, 15 de ellos no recibieron tratamiento farmacológico por haber sido diagnosticados tardíamente, 12 por falla al tratamiento farmacológico y 4 hubo alguna contraindicación médica para cierre farmacológico (sepsis, Insuficiencia renal aguda y/o alteraciones de la coagulación). No hubo muertes a consecuencia de la cirugía; los pacientes que fallecieron (5) fue entre 15-20 días posteriores a la cirugía, por otros problemas agregados. Todos los pacientes que sobrevivieron (26 pacientes) pudieron extubarse en un periodo de 2-5 días después de la cirugía. Conclusiones. El cierre quirúrgico de DAP es factible de llevar a cabo en un hospital de 2° nivel, cuando las indicaciones para cierre farmacológico no son posibles. Es un procedimiento sencillo, con complicaciones mínimas, que puede realizarse en la misma Unidad de Cuidados Intensivos Neonatales (UCIN), como demuestran nuestros resultados, con nula mortalidad transoperatoria.

Background: Patent ductus arteriosus (PDA) is the most common congenital cardiac defect affecting 80% of very low birth weight preterm newborns (<1 000 g) and is considered an important public health issue. The aim was to demonstrate that it is possible to perform surgical closure of PDA on premature newborns in a second-level hospital. Methods: We analyzed backgrounds and clinical evolution of 31 surgically treated patients with PDA. Criteria for surgical closure were 1) pharmacological closure failure, 2) pulmonary hypertension with left to right shunt, 3) echocardiogram with ductal diameter >1.5 mm, and Qs/Qp ratio (>1.5:1. 4) at >5 days of extrauterine life. All patients were operated using left posterolateral thoracotomy with extrapleural dissection and ductus closure with a 2-0 double silk ligature. Results: We studied 31 patients: 19 males and 12 females. Age range was between 30 and 35 weeks of gestational age. Birth weight was between 1 and 1.5 kg. Echocardiogram was confirmatory in 100% of patients; 15 patients did not have pharmacological closure, 12 had pharmacological closure failure, and 4 had medical contraindication for pharmacological closure (sepsis, renal failure and coagulation disturbances). There was no surgical mortality. In patients who died (five patients), it was after 15 or 20 postoperative days and due to problems unrelated to the surgical procedure. Conclusions: Surgical closure of PDA is feasible to perform in a second-level hospital with minimal complications. This was demonstrated with our results in those patients in whom pharmacological closure failed or was not indicated.

Cor triatriatum sinistrum: estrategia diagnóstica y terapéutica / Cor triatriatum a rare congenital cardiac malformation of diagnostic difficulty

Introducción. El cor triatriatum sinistrum es una membrana fibromuscular anómala en aurícula izquierda que la divide en 2 cavidades, con grados variables de obstrucción. Material y métodos. Estudio retrospectivo, longitudinal y descriptivo, que muestra 10 pacientes tratados en el Hospital Infantil de México Federico Gómez en 26 años, diagnosticados con ecocardiografía. Resultados. En ningún caso fue necesario realizar estudios adicionales ya que la ecocardiografía fue definitiva en el diagnóstico. La media de edad fue 16.9 meses; distribución por sexos 1:1. Dos pacientes murieron. El seguimiento a largo plazo promedió 46.8 meses en los 8 pacientes restantes. Conclusión. La ecocardiografía fue diagnóstica e identificó anomalías cardiacas congénitas asociadas. El abordaje por atriotomía derecha permitió una excelente exposición, la resección de la membrana obstructiva y la resolución de defectos asociados, demostrando ser la medida terapéutica definitiva. Esta es la serie pediátrica más grande reportada en nuestro país a la fecha.

Introduction. We define cor triatriatum sinistrum as an anomalous fibromuscular membrane in the left atrium which divides it into 2 cavities with variable degrees of obstruction. Material and methods. In this retrospective, longitudinal and descriptive study we show a series of ten patients treated at the Hospital Infantil de Mexico in a 26 year-experience diagnosed by echocardiography. Results. No additional studies were necessary. Median age was 16.9 months; sex distribution was 1:1, registering mortality in 2 patients (20%). Long-term follow-up in 8 remaining patients had a mean of 46.8 months. Echocardiography is diagnostic and identifies associated congenital cardiac anomalies; right atriotomy approach provides excellent exposure and allows resection of the obstructive membrane. It also allows resolution of associated defects and is the preferential approach. Conclusion. This is the largest pediatric series reported to date in our country.