The effect of modified ultrafiltration duration on pulmonary functions and hemodynamics in newborns and infants following arterial switch operation*.

OBJECTIVES: Modified ultrafiltration is used to ameliorate the deleterious effects of cardiopulmonary bypass in pediatric cardiac surgery patients. The ideal duration of modified ultrafiltration has not been established yet. We investigated the effects of extended duration of modified ultrafiltration on pulmonary functions and hemodynamics in the early postoperative period in newborns and infants who had transposition of great arteries operations. DESIGN: Single-center prospective randomized study. SETTING: Pediatric cardiac surgery operating room and ICU. PATIENTS: Sixty newborns and infants who had been scheduled to undergo transposition of great arteries operation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Modified ultrafiltration was applied to all patients following the termination of cardiopulmonary bypass (for 10, 15, and 20 min in groups 1, 2, and 3, respectively). Pulmonary compliance, gas exchange capacity, hemodynamic measurements, inotropic support, blood loss, transfusion requirements, hematocrit level, and duration of ventilatory support were measured after intubation, at termination of cardiopulmonary bypass, at the end of modified ultrafiltration, and in the 1st, 6th, 12th, and 24th hours after admission to ICU. The amount of fluid removed by modified ultrafiltration in groups 2 and 3 was larger than that of group 1 (p < 0.01). Systolic blood pressure was significantly increased at the end of modified ultrafiltration in group 3 compared to groups 1 and 2 (p < 0.05). Hematocrit levels were significantly increased at the end of modified ultrafiltration in groups 2 and 3 compared to group 1 (p < 0.01). Therefore, RBCs were transfused less after modified ultrafiltration in groups 2 and 3 compared to group 1 (p < 0.05). Static and dynamic compliance, oxygen index, and ventilation index had improved similarly in all three groups at the end of modified ultrafiltration (p > 0.05) CONCLUSIONS:: Modified ultrafiltration acutely improved pulmonary compliance and gas exchange in all groups. Increased hematocrit and blood pressure levels were also observed in the longer modified ultrafiltration group. However, extended duration of modified ultrafiltration did not have a significant impact on duration of intubation or the stay in ICU.

Anesthesia management with single injection paravertebral block for aorta coarctation in infant.

BACKGROUND: Thoracotomy causes severe pain in the postoperative period. Perioperative thoracic paravertebral block reduces pain score and may improve outcome after pediatric cardiac surgery. This prospective study was designed for the efficacy and duration of a single level, single injection ultrasound-guided thoracic paravertebral block (TPVB) for fifteen infants undergoing aortic coarctation repair. METHODS: After approval of the ethical committee and the relatives of the patients, 15 infants who had undergone thoracotomy were enrolled in the study. The patients received 0.5 ml·kg(-1) a bolus 0.25% bupivacaine with epinephrine 1 : 200 000 at T5-6 level after standard general anesthesia induction. Anesthesia depth with Index of Consciousness (IOC) and tissue oxygen saturation with cerebral (rSO2-C) and somatic thoracodorsal (rSO2-S) were monitored. Intraoperative hemodynamic and postoperative hemodynamic and pain scores were evaluated for 24 h after surgery. Face, Legs, Activity, Cry, Consolability (FLACC) score was utilized to measure postoperative pain in the intensive care unit. Rescue 0.05 mg·kg(-1) IV morphine was applied to patients in whom FLACC was >3. RESULTS: The median age of the patients was 4.5 (1-11) months, and the median intraoperative endtidal isoflurane concentration was 0.6% (0.3-0.8). The amount of remifentanil used intraoperatively was 4.5 (2.5-14) µg·kg(-) (1) ·h(-1). Intraoperative heart rate and blood pressure values significantly decreased compared with values detected at 5th, 10th, and 15th min after TPVB application, after incision prior and after cross-clamp (P < 0.01). The median time of first dose of morphine application after block was 320 (185-430) min. The median morphine consumption in 24 h was 0.16 (0.09-0.4) mg·kg(-1). The median length of postoperative intensive care unit and in-hospital stay times was 23 (1-67) h and 4 (1-10) days, respectively. CONCLUSION: We believe that TPVB, as part of a balanced anesthetic and analgesic regime, provides effective pain relief in patients undergoing aortic coarctation repair.

Early initiation of peritoneal dialysis after arterial switch operations in newborn patients.

BACKGROUND AND AIM: We investigated the clinical outcome of early initiated peritoneal dialysis (PD) use in our newborn patients who underwent arterial switch operation (ASO) for transposition of the great arteries (TGA) and had routine intraoperative PD catheter implantation. We determined the risk factors for PD, factors associated with prolonged PD, morbidity, and mortality. The aim of the present study was to describe our experience of using PD in this patient cohort. MATERIALS AND METHODS: Eighty two patients who were diagnosed with TGA and TGA-ventricular septal defect (VSD) and who had undergone TGA correction operation in Baskent University, Istanbul Medical Research and Training Hospital between 2007 and 2012 were retrospectively investigated. All the patients were under 30 days old. PD catheters were routinely implanted intraoperatively at the end of the operation. PD was initiated in transient renal insufficiency. In the absence of oliguria and increased creatinine level, PD was established in the presence of one of the following: clinical signs of fluid overload, hyperkalemia (>5 mEq/L), persistent metabolic acidosis, lactate level above 8 mmol/L or low cardiac output syndrome. The patients were divided into two groups according to the need for postoperative PD (PD group and non-PD group). PD was initiated in 32 (39%) patients after the operation, whereas 50 (61%) patients did not need dialysis. The clinical outcomes and perioperative data of the two groups were compared. RESULTS: The demographics in the two groups were similar. Cardiopulmonary bypass time was longer in the PD group [non-PD group, 175.24 ± 32.39 min; PD group, 196.22 ± 44.04 min (p < 0.05)]. Coronary anomaly was found to be higher in the PD group [non-PD group, n = 2 patients (4.0%); PD group, n = 7 patients (21.9%); p < 0.05]. There was more need for PD in TGA + VSD patients [simple TGA patients, n = 14; TGA + VSD patients, n = 18 (p < 0.05)]. PD rate was higher in patients whose sterna were left open at the end of the operation (p < 0.05). The ventilator time [non-PD group, 4.04 ± 1.51 days; PD group, 8.12 ± 5.21 days (p < 0.01)], intensive care unit stay time [non-PD group, 7.98 ± 5.80 days; PD group, 15.93 ± 18.31 days (p < 0.01)], and hospital stay time were significantly longer in the PD group [non-PD group, 14.98 ± 10.14 days; PD group, 22.84 ± 20.87 days (p < 0.01)]. CONCLUSION: We advocate routine implantation of PD catheters to patients with TGA-VSD, coronary artery anomaly, and open sternum in which we have determined high rate of postoperative PD need.

Does vertebral body tethering cause disc and facet joint degeneration? A preliminary MRI study with minimum two years follow-up.

BACKGROUND CONTEXT: Vertebral body tethering (VBT), a flexible compression-based growth modulation technique, was claimed to prevent disc degeneration due to its less rigid nature compared to other growth-friendly techniques. Yet, the consequences of VBT surgery on discs and facet joints have not been precisely acknowledged. PURPOSE: The purpose of this study was to determine the changes in the intermediate and adjacent levels at least 2 years after surgery. STUDY DESIGN/SETTING: Prospectively-followed consecutive patient cohort PATIENT SAMPLE: Adolescent idiopathic scoliosis patients who underwent thoracoscopic VBT between 2014 and 2017 were included. OUTCOME MEASURES: Degeneration of the intervertebral discs using the Pfirrmann classification; Degeneration of facet joints using a scale of 0 to 3. METHODS: Demographic, perioperative, clinical, radiographic data were collected. Skeletal maturity and height gain were assessed in every follow-up. Overcorrection, tether breakage, mechanical and pulmonary complications as well as readmission and reoperations were recorded. MRIs taken before surgery and at a minimum of 2 years follow-up were evaluated for degeneration at the intermediate and adjacent segment intervertebral discs and facet joints by a blinded senior radiologist and compared. RESULTS: Twenty-five patients with a mean of 38.6±10.6 months (24-62) of follow-up were included. The mean age at surgery was 12.2 (10-14), and the median Sanders stage was 3 (1-7). A mean of 7.7±1.1 (6-11) levels were tethered. The mean preoperative main thoracic curve magnitude of 46°±7.7° was corrected to 23.3°±5.9° postoperatively, which was subsequently modulated to 12° ±11.5° during the follow-up. At the time of the MRI (mean 29±9.5 (24-62) months), the median Sanders stages was 7 (5-8). A total of 217 levels of discs and bilateral facet joints were evaluated in the preoperative and follow-up MRI images. Analyses of disc and facet scores revealed no significant differences between patients. Deterioration of previously degenerated discs was noted in one patient (from grade 2 to 3), while previously healthy lower adjacent facet joints were degenerated (grade 2) in another patient. CONCLUSIONS: Intermediate discs and facet joints were preserved after growth modulation with VBT surgery at a mean of 29 months of follow-up. Studies in larger cohorts with longer follow-up are warranted to have more in-depth analyses of the effects of relative stabilization and altered biomechanical loads.

The effects of different ventilator modes on cerebral tissue oxygen saturation in patients with bidirectional superior cavopulmonary connection.

AIMS AND OBJECTIVES: We used near-infrared spectroscopy to document changes in cerebral tissue oxygen saturation (SctO2) in response to ventilation mode alterations after bidirectional Glenn (BDG; superior cavopulmonary connection) procedure. We also determined whether spontaneous ventilation have a beneficial effect on hemodynamic status, lactate and SctO2 when compared with other ventilation modes. MATERIALS AND METHODS: 20 consecutive patients undergoing BDG were included. We measured SctO 2 during three ventilator modes (intermittent positive-pressure ventilation [IPPV]; synchronized intermittent mandatory ventilation [SIMV]; and continuous positive airway pressure + pressure support ventilation [CPAP + PSV]). We, also, measured mean airway pressure (AWP), arterial blood gases, lactate and systolic arterial pressures (SAP). RESULTS: There was no change in SctO2 in IPPV and SIMV modes; the SctO2 measured during CPAP + PSV and after extubation increased significantly (60.5 ± 11, 61 ± 10, 65 ± 10, 66 ± 11 respectively) (P < 0.05). The differences in the SAP measured during IPPV and SIMV modes was insignificant; the SAP increased significantly during CPAP + PSV mode and after extubation compared with IPPV and SIMV (109 ± 11, 110 ± 12, 95 ± 17, 99 ± 13 mmHg, respectively) (P < 0.05). Mean AWP did not change during IPPV and SIMV modes, mean AWP decreased significantly during CPAP + PSV mode (14 ± 4, 14 ± 3, 10 ± 1 mmHg, respectively) (P < 0.01). CONCLUSIONS: The SctO2 was higher during CPAP + PSV ventilation and after extubation compared to IPPV and SIMV modes of ventilation. The mean AWP was lower during CPAP + PSV ventilation compared to IPPV and SIMV modes of ventilation.