Assessment of microcirculatory alteration by a vascular occlusion test using near-infrared spectroscopy in pediatric cardiac surgery: effect of cardiopulmonary bypass.

OBJECTIVES: Cardiopulmonary bypass cause microcirculatory alterations. Near infrared spectroscopic measurement of tissue oxygen saturation and vascular occlusion test are novel technologies for assessing the microcirculatory function of peripheral tissue specifically in patients undergoing cardiac surgery with cardiopulmonary bypass.Our study aimed to evaluate dynamic microcirculatory function using the vascular occlusion testing during cardiac surgery in pediatric patients. METHODS: 120 pediatric patients were scheduled. Children had continuous regional oxygen saturation monitoring using near infrared spectroscopy and vascular occlusion test. Vascular occlusion test was performed five times; before induction (T1), after induction (T2), then during cardiopulmonary bypass with full flow (T3), after the termination of CPB (T4) and after sternum closure (T5). RESULTS: Basal value was the lowest at T3 and this value was significantly different among measurements (p < 0,01).Values for maximum and minimum tissue oxygen saturation were the lowest at T3 (83,4 and 52,9%).The occlusion slope varied significantly among measurements (p < 0,01).Reperfusion slopes were significantly different among measurements (p < 0,01) with a further progressive decrease in reperfusion slope with duration of cardiopulmonary bypass. CONCLUSION: Microcirculatory function can assessed using VOT with forearm Near-infrared spectroscopy derived variables during cardiopulmonary bypass in pediatric cardiac surgery. Noninvasive assessment of microcirculatory perfusion during cardiopulmonary bypass can further help evaluate and improve circulatory support techniques. TRIAL REGISTRATION: The research Project was registered at ClinicalTrials.gov (NCT06191913).

A 5-year analysis of Candida bloodstream infections in the paediatric cardiovascular surgery ICU of a tertiary care centre.

BACKGROUND: Candida infections have become one of the most common causes of morbidity and mortality in paediatric ICUs, especially following complex surgeries, all over the world. Therefore, we conducted a 5-year analysis of Candida bloodstream infections in our tertiary paediatric cardiovascular surgery ICU. METHODS: One thousand nine hundred and thirty four children, 0-16-year-old, who underwent paediatric cardiovascular surgery between January 2016-June 2021 were enrolled in this retrospective study. Blood cultures obtained from 1056 patients, who needed mechanical ventilation and indwelling devices longer than 5 days and had the signs of infection according to Center for Disease Control criteria, were evaluated. The isolated pathogens were recorded. 137 with Candida bloodstream infections were reanalysed for their age, weight, cardiac pathologies, duration of mechanical ventilation, hospitalisation and antibiotic use. RESULTS: One hundred and thirty-seven out of one thousand and fifty six patients (12.9%) had Candida growth in their blood cultures. C. albicans (n: 50, 36.5%), C. parapsilosis (n: 20, 14.6%), C. tropicalis (n: 8, 5.8%), C. glabrata (n: 5, 3.7%), and other non-albicans Candida species (n: 54, 39.4%) were isolated. The patients with Candida bloodstream infections had lower age, longer duration of mechanical ventilation, longer length of hospital stay and antibiotic use (p-values<0.05). They had cardiac pathologies as atrioventricular septal defect (18.9%), transposition of great arteries (17.6%), tetralogy of Fallot (12.4%), transposition of great arteries + double outlet right ventricle, or total anomalous pulmonary venous return + atrioventricular septal defect (37.9%), and others. The Candida bloodstream infections mortality was 11.6% (16/137). CONCLUSION: The most common cause of Candida bloodstream infections in the last five years in our paediatric cardiovascular surgery ICU was non-albicans Candida species. Prolonged mechanical ventilation, hospitalisation and antibiotic use, low age, and weight were found as the main risk factors that raise the morbidity and mortality rates of Candida bloodstream infections.

Infection profile of patients with extracorporeal membrane oxygenation in paediatric cardiac surgery ICU.

AIM: We investigated the risk of increased nosocomial infections and the associated pathogens in patients who underwent paediatric cardiovascular surgery and were put on extracorporeal membrane oxygenation support. We studied the duration of extracorporeal membrane oxygenation use and other variables that may be associated with increased nosocomial infection risk. METHODS: Patients who were treated with an extracorporeal membrane oxygenation in paediatric cardiovascular surgery ICU between 2010 and 2020 were included in this retrospective study. We analysed the site of infection and microbiological profile of infections occurring in these patients according to CDC and National Healthcare Safety Network criteria. RESULTS: The onset of infection development in patients after extracorporeal membrane oxygenation was found to be median 8 (3-15, 25-75 IQR) days in the whole group, and median 11 (3-16, 25-75 IQR) days in those who developed infection without being put on extracorporeal membrane oxygenation. When patients were divided into those with and without infection, duration of ICU was found to be 19 (16-28, IQR 25-75) days in patients with infection vs. 8 (2-16, IQR 25-75; p: <0.001) days in patients without infection. Duration of extracorporeal membrane oxygenation support was found to be 14 (10-25, IQR 25-75) days in patients with infection versus 5 (2-10, IQR 25-75; p: <0.001) days in patients without infection and total hospital stay was 26 (18-33, IQR 25-75) days in patients with infection versus 8 (2-23, IQR 25-75) days in those without infection. A total of 24 patients out of the 70 patients experienced 32 infectious episodes during extracorporeal membrane oxygenation support. Culture-positive infections were detected at a single site in 19 patients, and multiple sites in 5 patients. CONCLUSION: We propose that prolonged extracorporeal membrane oxygenation support is associated with an increased risk of infection. Although extracorporeal membrane oxygenation is a life-saving treatment method, prolonged extracorporeal membrane oxygenation may increase the development of infectious complications and the associated mortality and morbidity of the patient.

Acute Changes in Myocardial Expression of Heat Shock Proteins and Apoptotic Response Following Blood, delNido, or Custodiol Cardioplegia in Infants Undergoing Open-Heart Surgery.

Stress caused by cardioplegic ischemic arrest was shown to alter the expression levels of heat shock proteins (Hsp), but little is known about their effects, particularly on pediatric hearts. This study aimed to investigate whether myocardial cellular stress and apoptotic response changes due to different cardioplegia (CP) solutions during cardiopulmonary bypass (CPB) in infants and to determine their influence on surgical/clinical outcomes. Therefore, twenty-seven infants for surgical closure of ventricular septal defect were randomly assigned to a CP solution: normothermic blood (BCP), delNido (dNCP), and Custodiol (CCP). Hsp levels and apoptosis were determined by immunoblotting in cardiac tissue from the right atrium before and after CP, and their correlations with cardiac parameters were evaluated. No significant change was observed in Hsp27 levels. Hsp60, Hsp70, and Hsp90 levels decreased significantly in the BCP-group but increased markedly in the CCP-group. Decreased Hsp60 and increased Hsp70 expression were detected in dNCP-group. Importantly, apoptosis was not observed in dNCP- and CCP-groups, whereas marked increases in cleaved caspase-3 and -8 were determined after BCP. Serum cardiac troponin-I (cTn-I), myocardial injury marker, was markedly lower in the BCP- and dNCP-groups than CCP. Additionally, Hsp60, Hsp70, and Hsp90 levels were positively correlated with aortic cross-clamp time, total perfusion time, and cTn-I release. Our findings show that dNCP provides the most effective myocardial preservation in pediatric open-heart surgery and indicate that an increase in Hsp70 expression may be associated with a cardioprotective effect, while an increase in Hsp60 and Hsp90 levels may be an indicator of myocardial damage during CPB.

Neurological complications after pediatric cardiac surgery.

Background: The number of pediatric patients who survive open-heart surgery has increased in recent years and the complications seen in this patient group continue to decrease with each technological advance, including new surgical and neuroprotective techniques and the improvement in surgeons' experience with this patient population. However, neurological complications, which are the most feared and difficult to manage, require long-term follow-up, and increase hospital costs remain a leading cause of mortality and morbidity in this cohort. Results: We evaluated the neurological physical examination, cranial computed tomography (CT), and magnetic resonance (MRI) records of 162 pediatric patients with neurological symptoms lasting more than 24 h after undergoing heart surgery in our clinic between June 2012 and May 2020. The patients' ages ranged from 0 to 205 months, with a mean of 60.59 ± 46.44 months.Of the 3849 pediatric cardiac surgery patients we screened, 162 had neurological complications in the early period (the first 10 days after surgery). The incidence was calculated as 4.2%; 69 patients (42.6%) experienced seizures, 17 (10.5%) experienced confusion, 39 (24.1%) had stupor, and 37 (22.8%) had hemiparesis. Of the patients who developed neurological complications, 54 (33.3%) died. Patients with neurological complications were divided into 3 groups: strokes (n = 90), intracranial bleeding (n = 37), and no radiological results (n = 35). Thirty-four patients (37.8%) in the stroke group died, as did 15 (40%) in the bleeding group, and 5 (14.3%) in the no radiological results group. Conclusions: Studies on neurological complications after pediatric heart surgery in the literature are currently insufficient. We think that this study will contribute to a more detailed discussion of the issue. Responses to neurological events and treatment in the pediatric group may differ compared to the adult age group. Primary prevention methods should be the main approach in combating neurological complications; their formation mechanisms should be carefully monitored and preventive treatment strategies should be developed.

Effects of anticoagulant drugs on wound healing process in a rat model: a comparative study.

OBJECTIVE: This study aims to compare the efficacy of enoxaparin, rivoraxaban and dabigatran on wound healing using a rat model. METHOD: Sprague-Dawley female rats (n=56), 10-12 weeks old, weight 245±30g, were used in this study. The rats were divided into four equally-sized groups. A type 1 (secondary wound healing) and type 2 (primary wound healing) wound was opened surgically on each rat in each group. Anticoagulent drugs enoxaparin, rivoraxaban and dabigatran and physiological saline solution were administered to Groups 1, 2, 3 and 4, respectively. After wound healing was scored tissue samples were taken from euthanised rats at days five and 10 and examined histologically. Since time was used as a classification (days five and 10), a time effect was included. RESULTS: There was no statistically significant difference in total score distribution in rats between type 1 secondary wounds for days five and 10 (p>0.05). There was no statistically significant difference in the overall score distribution in rats between type 2 primary wounds for days five and 10 (p>0.05). CONCLUSION: In addition to the use of low molecular weight heparin with well-known anticoagulation activity, the new generation oral medications are used efficiently in thromboembolic diseases. However, there was no evidence observed in this study that these drugs could be either beneficial or harmful to wound healing.

Neutrophil-lymphocyte ratio as a mortality predictor for Norwood stage I operations.

BACKGROUND: Hypoplastic left heart syndrome is a lethal congenital heart malformation when untreated resulting in a 95% mortality in the first month of life. In this study, we aimed to investigate the newly introduced inflammatory biomarker, neutrophil-lymphocyte ratio, as a mortality predictor in postoperative hypoplastic left heart syndrome patients. METHODS: Patients were divided into two groups; Group 1 consisted of 33 patients who were discharged and Group 2 including 20 patients who were deceased following surgery. Patients' preoperative demographic characteristics, total white blood cell counts, neutrophil counts, lymphocyte counts, neutrophil-lymphocyte ratio, C-reactive proteins, alanine aminotransferase, aspartate transaminase, urea, and creatinine levels were recorded. Studys' primary endpoint was all-cause patient mortality following surgery. RESULTS: The preoperative neutrophil-lymphocyte ratio was found to be significantly different between the groups (p = 0.001). High neutrophil-lymphocyte ratio was found to be associated with an increased risk of death. The ROC curves of neutrophil-lymphocyte ratio were found to be associated with mortality. The area under curve for the preoperative neutrophil-lymphocyte ratio was 0.74. Neutrophil-lymphocyte ratio predicted mortality with a sensitivity of 78% and a specificity of 65%. CONCLUSION: Neutrophil-lymphocyte ratio can contribute to the early identification of patients at high risk for complications. In addition, through the use of NLR, clinicians could implement measures for the optimal therapeutic approach of cardiac surgery patients and the elimination of adverse patient outcomes.

Comparison between iloprost and alprostadil for protection against ischemia/reperfusion injury in a rat model

Background/aim: Alprostadil and iloprost are successful agents used for both pulmonary hypertension and extremity ischemia treatment. Different systemic effects of these agents may change the preferences of clinical usage. Superiority of preventing ischemia/ reperfusion (IR) injury is a criterion for clinical preference of these agents. The present study was designed to compare the protective effects of alprostadil and iloprost in a rat model of IR injury. Materials and methods: Twenty-three male Sprague Dawley rats were used (aged 8-12 weeks, mean weight 230 ± 30 g). They were randomized into 4 groups: Group 1 (iloprost + IR), Group 2 (alprostadil + IR), Group 3 (saline + IR), and Group 4 (control). Under general anesthesia, in all groups except Group 4, the abdominal region was explored and the abdominal aorta was temporarily clamped for 60 min. After the clamp was removed, 120 min of reperfusion was applied. In Group 4, the rats were placed under general anesthesia and abdominal exploration was performed without the IR procedure. For all rats, body temperature was kept at 36 °C with a heater pad through the whole procedure. The rats were euthanized under general anesthesia to remove the kidneys and lungs for study. Histopathological and biochemical analyses were conducted with kidney and lung tissues. Histopathological scoring was done by analyzing cellular damage at tissue level. Malondialdehyde (MDA), superoxide dismutase, and glutathione levels were studied for biochemical analysis. Results: Histopathologic analysis showed that, as compared with alprostadil, iloprost provided a significantly higher level of renal protection against IR injury (P < 0.01). Renal tissue levels of MDA were significantly lower in the alprostadil group as compared to Group 3 (P < 0.05). Conclusion: Alprostadil and iloprost seem to provide protection against IR injury, with iloprost being more protective in renal tissue. Alprostadil is more effective than iloprost in protecting lung tissue against IR injury.

N-acetylcysteine versus Dopamine to Prevent Acute Kidney Injury after Cardiac Surgery in Patients with Preexisting Moderate Renal Insufficiency.

Objective: Acute kidney injury after cardiac surgery is associated with mortality and morbidity. Therefore, strategies to prevent acute kidney injury are very important. The aim of this placebo-controlled randomized double-blind study was to compare the prophylactic efficacy of N-Acetylcysteine and dopamine administration in patients with pre-existing moderate renal insufficiency who were undergoing cardiopulmonary bypass. Methods: This study included 135 patients with pre-existing moderate renal insufficiency who were scheduled for coronary artery bypass grafting surgery. Serum creatinine and GFR were recorded preoperatively and on the first and second postoperative days. Results: On the first and second postoperative days, the drugs used showed statistically significant differences among the creatinine groups (P<0.001). According to Tukey's HSD, on the first and second PO, the creatinine of Group N, D and P were significantly different (P<0.001). On the first and second PO, the used drugs showed statistically significant differences among the effects of eGFR (P<0.001). According to Tukey's HSD on the first postoperative day, the average eGFR score of Group N compared to D and P were significantly difference (P<0.001). On the second postoperative day, the eGFR of Group N and D showed no difference (P=0.37), but P showed a difference (P<0.001). Conclusion: We found that the prophylactic use of intravenous N-Acetylcysteine had a protective effect on renal function, whereas the application of renal dose dopamine did not have a protective effect in patients with pre-existing moderate renal failure.

N-acetylcysteine versus dopamine to prevent acute kidney injury after cardiac surgery in patients with preexisting moderate renal insufficiency

Abstract Objective: Acute kidney injury after cardiac surgery is associated with mortality and morbidity. Therefore, strategies to prevent acute kidney injury are very important. The aim of this placebo-controlled randomized double-blind study was to compare the prophylactic efficacy of N-Acetylcysteine and dopamine administration in patients with pre-existing moderate renal insufficiency who were undergoing cardiopulmonary bypass. Methods: This study included 135 patients with pre-existing moderate renal insufficiency who were scheduled for coronary artery bypass grafting surgery. Serum creatinine and GFR were recorded preoperatively and on the first and second postoperative days. Results: On the first and second postoperative days, the drugs used showed statistically significant differences among the creatinine groups (P<0.001). According to Tukey’s HSD, on the first and second PO, the creatinine of Group N, D and P were significantly different (P<0.001). On the first and second PO, the used drugs showed statistically significant differences among the effects of eGFR (P<0.001). According to Tukey’s HSD on the first postoperative day, the average eGFR score of Group N compared to D and P were significantly difference (P<0.001). On the second postoperative day, the eGFR of Group N and D showed no difference (P=0.37), but P showed a difference (P<0.001). Conclusion: We found that the prophylactic use of intravenous N-Acetylcysteine had a protective effect on renal function, whereas the application of renal dose dopamine did not have a protective effect in patients with pre-existing moderate renal failure.

Do preoperative oral carbohydrates improve postoperative outcomesin patients undergoing coronary artery bypass grafts?

Background/aim: The aim of this prospective study was to determine whether the preoperative oral intake of carbohydrate-rich drinks by patients undergoing a coronary artery bypass graft attenuates postoperative insulin requirements, improves postoperative patient discomfort, provides inotropic support, shortens the length of the ICU stay, and shortens the duration of postoperative mechanical ventilation. Materials and methods: This randomized prospective clinical study included 152 patients with coronary artery disease who were divided into 4 groups. Carbohydrates were administered to 3 groups at different hours and doses before operation. The fourth group had an 8-h preoperative fasting period. The inotropic and vasopressor requirements, ventilation time, and ICU stay time were recorded for all of the groups. Patient wellbeing, mouth dryness, hunger, anxiety, and nausea were assessed using VAS scores of 1-10. Results: Mouth dryness and hunger were significantly higher in the control group (P = 0.03, P = 0.02). The increase in blood glucose level was significantly higher in the control group (P = 0.04). The exogenous insulin requirement was significantly higher in the control group than in the other groups (P = 0.04). Conclusion: The administration of carbohydrates before elective cardiac surgery reduced insulin resistance. Based on the VAS scores, the intake of carbohydrates reduced mouth dryness and hunger. Overall, preoperative oral carbohydrate treatments can improve the postoperative outcomes of coronary artery bypass graft surgeries.

Sedation for transesophageal echocardiography: comparison of propofol, midazolam and midazolam-alfentanil combination.

AIM: The administration of trans esophageal echocardiography (TEE) may cause nausea, shortness of breath, agitation, emotional distress and pain in patients due to pharyngo-esophageal intubation, which may be partially relieved by sedoanalgesia. The aim of this study was to compare clinical effects of midazolam, midazolam-alfentanil combination and propofol sedation given for sedation and sedoanalgesia to patients with planned diagnostic TEE interventions. METHODS: This study was prospectively completed with 90 randomized adult patients in ASA risk groups I-II-III. Group M were given 2.5 mg midazolam, group MA were given 1 mg midazolam and 5 µg/kg alfentanil and group P were given 0.5 mg/kg propofol intravenous bolus. If necessary, additional doses were administered. Patients administered with TEE were evaluated in terms of additional dose requirements, Ramsey Sedation Scale (RSS), modified Aldrete Scoring (MAS), recovery time and duration of stay in the hospital. RESULTS: In the group P additional dose requirements were greater (p<0.05), as well as the duration of stay in the recovery unit and hospital were shorter (p<0.05). On insertion of the TEE probe, the RSS in the group P was clearly higher than in other groups M and MA (p<0.05). CONCLUSION: During the TEE intervention, the use of propofol, contrary to requirements for additional dose and observation of apnea, appears to be advantageous due to providing more rapid and effective sedation depth without a need of expensive antagonist agents, and allowing early discharge of patients. Additionally, it seems that the use of midazolam combined with alfentanil, is more advantageous comparing to midazolam alone.