Pulmonary Flow Management by Combination Therapy of Hemostatic Clipping and Balloon Angioplasty for Right Ventricular-Pulmonary Artery Shunt in Hypoplastic Left Heart Syndrome.

Controlling pulmonary blood flow in patients who have undergone Norwood palliation, especially early postoperatively, is challenging due to a change in the balance of systemic and pulmonary vascular resistance. We applied a combination therapy of clipping and balloon angioplasty for right ventricle-pulmonary artery (RV-PA) shunt to control pulmonary blood flow, but the influence of the combination therapy on the PA condition is uncertain. Retrospectively analysis was conducted of all infants with hypoplastic left heart syndrome who had undergone Norwood palliation with RV-PA shunt at Okayama University Hospital from January 2008 to September 2022. A total of 50 consecutive patients underwent Norwood palliation with RV-PA shunt in this study period. Of them, 29 patients underwent RV-PA shunt flow clipping, and the remaining 21 had unclipped RV-PA shunt. Twenty-three patients underwent balloon angioplasty for RV-PA shunt with clips. After balloon angioplasty, oxygen saturation significantly increased from 69 (59-76)% to 80 (72-86)% (p < 0.001), and the narrowest portion of the clipped conduit significantly improved from 2.8 (1.8-3.4) to 3.8 (2.9-4.6) mm (p < 0.001). In cardiac catheterizations prior to Bidirectional cavo-pulmonary shunt (BCPS), there were no significant differences in pulmonary-to-systemic flow ratio (Qp/Qs), ventricular end-diastolic pressure, Nakata index, arterial saturation, mean pulmonary artery pressure and pulmonary vascular resistance index. On the other hand, in Cardiac catheterizations prior to Fontan, Nakata index was larger in the clipped group (p = 0.02). There was no statistically significant difference in the 5-year survival between the two groups (clipped group 96%, unclipped group 74%, log-rank test: p = 0.13). At least, our combination therapy of clipping and balloon angioplasty for RV-PA shunt did not negatively impact PA growth. Although there is a trend toward better but not statistically significant difference in outcomes in the clipped group compared to the non-clipped group, this treatment strategy may play an important role in improving outcomes in hypoplastic left heart syndrome.

Modified del Nido cardioplegia is associated with low incidence of low main strong ion difference and hyperchloremia in pediatric patients after cardiac surgery.

PURPOSE: The aims of this study were (1) to determine the associations of cardioplegic solutions with postoperative main strong ion difference (mSID), which is the difference between sodium ion concentration and chloride ion concentration ([Cl-]) and (2) to determine the associations of cardioplegic solutions with markers of organ dysfunction. METHODS: In this retrospective cohort study, patients aged <5 years who underwent cardiac surgery in a tertiary teaching hospital were included. Patients were classified on the basis of the type of cardioplegic solution: modified del Nido cardioplegia (mDNC) and conventional cardioplegia (CC). The effects of mDNC on postoperative mSID and markers of organ functions were examined using propensity-matched analysis. RESULTS: A total of 500 cases were included. mDNC solution was used in 163 patients (32.6%). After propensity score matching, patients in the mDNC group (n = 152) had significantly higher minimum mSID [28 (26, 30) mEq/L vs. 27 (25, 29) mEq/L, p = 0.02] and lower maximum [Cl-] [112 (109, 114) mEq/L vs. 113 (111, 117) mEq/L, p < 0.001] than patients in the CC group (n = 304). The incidences of low mSID and hyperchloremia in the mDNC group were significantly lower than those in the CC group (63.8 vs. 75.7%, p = 0.01 and 63.2 vs. 79.3%, p < 0.001, respectively). There was no significant difference in the incidence of postoperative acute kidney injury and B-type natriuretic peptide level between the two groups. CONCLUSION: The use of modified del Nido cardioplegia may reduce the incidence of abnormal mSID and hyperchloremia compared with the use of a chloride-rich cardioplegic solution.

General Anesthesia With Remimazolam During Minimally Invasive Cardiac Surgery for Atrial Septal Defect: A Pediatric Case Report.

Remimazolam is a new ultrashort-acting benzodiazepine sedative, the use of which has not been reported for pediatric cardiac surgery. This case report describes the use of remimazolam in a 6-year-old girl who underwent minimally invasive cardiac surgery with right-sided thoracotomy for an atrial septal defect. Under electroencephalographic monitoring, remimazolam (2-4 mg kg-1 h-1) and remifentanil (0.05 µg kg-1 min-1) were administered with an intercostal nerve block during the procedure. The patient awoke and was extubated promptly after surgery, without any serious adverse events, including intraoperative awareness. Remimazolam may be a viable option for general anesthesia during pediatric cardiac surgery.

Relationship of Intraoperative SpO2 and ETCO2 Values with Postoperative Hypoxemia in Elderly Patients after Non-Cardiac Surgery.

Elderly patients are at higher risk of postoperative hypoxemia due to their decreased respiratory function. The aim of this study was to investigate the relationship of intraoperative oxygen saturation (SpO2) and end-expiratory carbon dioxide (ETCO2) values with postoperative hypoxemia in elderly patients. The inclusion criteria were: 1) patients aged≥75 years; 2) underwent general anesthesia in non-cardiac surgery; 3) operative time longer than two hours; and 4) admission to the intensive care unit (ICU) following surgery performed between January and December 2019. Intraoperative SpO2 and ETCO2 values were collected every minute for the first two hours during surgery. The 253 patients were divided into two groups: SpO2≥92% and SpO2<92%. The time-weighted averages of intraoperative SpO2 and ETCO2 were used to compare differences between the two groups. The incidence of postoperative hypoxemia was 22.5%. For similar ventilator settings, patients with postoperative hypoxemia had lower intraoperative SpO2 and higher ETCO2 values. Sex, ASA classification, and intraoperative SpO2 were independent risk factors for postoperative hypoxemia. In conclusion, postoperative SpO2<92% was a frequent occurrence (> 20%) in elderly patients who underwent major non-cardiac surgery. Postoperative hypoxemia was associated with low intraoperative SpO2 and relatively higher ETCO2.

Carboxyhemoglobin and Methemoglobin Levels and Hemolysis in Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass.

Hemolysis is a complication of cardiopulmonary bypass (CPB). Carboxyhemoglobin (COHb) and methemoglobin (MetHb) were suggested as potential hemolysis biomarkers. This retrospective study was based on a prospective registry aimed to determine the association of COHb and MetHb levels with hemolysis in pediatric patients <4 years old who underwent cardiac surgery with CPB. Plasma-free hemoglobin (PFH), COHb, and MetHb levels were measured before CPB; every 30 minutes during CPB; and on postoperative days 1, 2, and 3. Patients were classified into hemolysis and nonhemolysis groups based on the maximum PFH levels during CPB. A total of 193 patients were included. No significant difference was observed in the maximum COHb levels during CPB (COHb CPB ) between the hemolysis and nonhemolysis groups (1.2% [interquartile range {IQR} 0.9-1.4%] vs. 1.1% [IQR: 0.9-1.4%]; p = 0.17). The maximum MetHb levels during CPB (MetHb CPB ) were significantly higher in the hemolysis group than in the nonhemolysis group (1.3% [IQR: 1.1-1.5%] vs. 1.2% [IQR: 1.0-1.4%]; p = 0.007). Areas under the receiver operating curves of COHb CPB and MetHb CPB were 0.557 (95% confidence interval: 0.475-0.640) and 0.615 (95% confidence interval: 0.535-0.695), respectively. Therefore, the predictive ability of both hemolysis biomarkers during CPB is limited.

Regional Cerebral Oxygen Saturation and Estimated Oxygen Extraction Ratio as Predictive Markers of Major Adverse Events in Infants with Congenital Heart Disease.

Regional cerebral oxygen saturation (ScO2) determined by near-infrared spectroscopy, monitoring both arterial and venous blood oxygenation of the brain, could reflect the balance between oxygen delivery and consumption. The aim of this study was to determine the predictabilities of ScO2 and estimated oxygen extraction ratio (eO2ER) with outcomes in infants with congenital heart disease (CHD). This study was a two-center, retrospective study of patients at 12 months of age or younger with CHD who underwent cardiac surgery. The primary outcome was a composite of one or more major adverse events (MAEs) after surgery: death from any cause, circulatory collapse that needed cardiopulmonary resuscitation, and requirement for extracorporeal membrane oxygenation. Based on the assumptions of arterial to venous blood ratio, eO2ER was calculated. A total of 647 cases were included in this study. MAEs occurred in 16 patients (2.5%). There were significant differences in post-bypass ScO2 [46.61 (40.90, 52.05) vs. 58.52 (51.52, 66.08), p < 0.001] and post-bypass eO2ER [0.66 (0.60, 0.78) vs. 0.52 (0.43, 0.61), p < 0.001] between patients with MAEs and patients without MAEs. Area under the receiver operating curve (AUROC) of post-bypass ScO2 was 0.818 (95% confidence interval: 0.747-0.889), AUROC of post-bypass eO2ER was 0.783 (0.697-0.870) and AUROC of post-bypass maximum serum lactate level was 0.635 (0.525-0.746). Both ScO2 and eO2ER, especially after weaning off bypass, are acceptable predictive markers for predicting MAEs after cardiac surgery in infants.(227 words).

Efficacy of prophylactic high-flow nasal cannula therapy for postoperative pulmonary complications after pediatric cardiac surgery: a prospective single-arm study.

PURPOSE: This study investigated the incidence of postoperative pulmonary complications (PPC) when high-flow nasal cannula therapy (HFNC) is used prophylactically after pediatric cardiac surgery, and evaluated its efficacy. METHODS: This was a single-arm prospective interventional study that was conducted in a tertiary teaching hospital with eight beds in the pediatric cardiac ICU after approval by the Ethics Committee. One-hundred children under the age of 48 months who were scheduled for cardiac surgery for congenital heart disease were recruited. HFNC was used for 24 h after extubation at a 2 L/kg/min flow rate. The primary outcome was the incidence of PPC within 48 h after extubation. PPC was defined as atelectasis and acute respiratory failure meeting certain criteria. We considered prophylactic HFNC as effective if the prevalence of PPC was < 10%, based on previous reports of reintubation rates of 6%-9% after pediatric cardiac surgery. RESULTS: A total of 91 patients were finally included in the analysis. The incidence of PPC within 48 h after extubation was 18.7%, whereas atelectasis was observed in 13.2%, and acute respiratory failure in 8.8%. Reintubation rate within 48 h after extubation was 0%. CONCLUSIONS: We found the incidence of PPC with prophylactic HFNC after planned extubation after pediatric cardiac surgery. However, the incidence was > 10%; therefore, we could not demonstrate its efficacy in this single-arm study. Further studies are needed to investigate whether the HFNC could be adapted as first-line oxygen therapy after pediatric cardiac surgery.

Outcomes associated with unrecognized acute kidney injury in postoperative pediatric cardiac patients.

BACKGROUND: The present retrospective study was carried out to determine the incidence of unrecognized cardiac surgery-associated acute kidney injury (CSA-AKI) due to infrequency of serum creatinine (SCr) measurements in pediatric cardiac patients and to assess the association between unrecognized CSA-AKI and clinical outcomes. METHODS: This study was a single-center, retrospective study of pediatric patients who underwent cardiac surgery. Patients were diagnosed with CSA-AKI based on SCr measurements, and unrecognized CSA-AKI was defined under the assumptions that there had been only one or two SCr measurements within 48 h after surgery: CSA-AKI unrecognized by one SCr measurement (AKI-URone), CSA-AKI unrecognized by two SCr measurements (AKI-URtwo), and CSA-AKI recognized by one and two SCr measurements (AKI-R). The change of SCr from baseline to postoperative day 30 (delta SCr30d) was assessed as a surrogate of kidney recovery. RESULTS: In a total of 557 cases, 313 patients (56.2%) were diagnosed with CSA-AKI, 188 (33.8%) of whom had unrecognized CSA-AKI. Delta SCr30d in the AKI-URtwo group and delta SCr30d in the AKI-URone group was not significantly different from delta SCr30d in the non-AKI group (p = 0.67 and p = 0.79, respectively). There were significant differences in the durations of mechanical ventilation, serum B-type natriuretic peptide levels, and lengths of stay in hospital between the non-AKI group and the AKI-URtwo group and between the non-AKI group and the AKI-URtwo group. CONCLUSIONS: Unrecognized CSA-AKI due to infrequent SCr measurements is not rare and is associated with prolonged mechanical ventilation, high postoperative BNP level, and prolonged length of stay in hospital. A higher resolution version of the Graphical abstract is available as Supplementary information.

An Assessment of the Practice of Neuromuscular Blockade and the Association Between Its Prophylactic Use and Outcomes Among Postoperative Pediatric Cardiac Patients.

OBJECTIVES: The authors investigated the management of neuromuscular blocking agents (NMBAs) for pediatric patients after cardiac surgery, and compared the outcomes of patients who received prophylactic NMBA (pNMBA) infusions and patients without pNMBA infusions. DESIGN: A retrospective cohort study. SETTING: At a tertiary teaching hospital. PARTICIPANTS: Patients younger than 18, with congenital heart disease, who underwent cardiac surgery. INTERVENTIONS: Commencement of NMBA infusion in the first 2 hours after surgery MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a composite of one or more of the following major adverse events (MAEs) that occurred within 7 days after surgery: death from any cause, a circulatory collapse that needed cardiopulmonary resuscitation, and requirement for extracorporeal membrane oxygenation. The secondary endpoints included the total duration of mechanical ventilation for the first 30 days after surgery. A total of 566 patients were included in this study. The MAEs occurred in 13 patients (2.3%). An NMBA was commenced within 2 hours after surgery in 207 patients (36.6%). There were significant differences in the incidence of postoperative MAEs between the pNMBA group and the non-pNMBA group (5.3% v 0.6%; p < 0.001). In multivariate regression models, pNMBA infusion was not significantly associated with the incidence of MAEs (odds ratio: 1.79, 95% CI: 0.23-13.93, p = 0.58), but was significantly associated with prolonged mechanical ventilation by 3.85 days (p < 0.001). CONCLUSIONS: Postoperative prophylactic neuromuscular blockade after cardiac surgery can be associated with prolonged mechanical ventilation, but has no association with MAEs among pediatric patients with congenital heart disease.

Therapeutic plasma exchange in postpartum HELLP syndrome: a case report.

BACKGROUND: Postpartum hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is more difficult to treat than HELLP syndrome during pregnancy. We describe a case of postpartum HELLP syndrome that responded to plasma exchange (PE) therapy. CASE PRESENTATION: A 30-year-old primipara woman was hospitalized for gestational hypertension at 33 weeks of gestation and underwent an emergent cesarean section at 36 weeks and 6 days of gestation due to rapidly progressing pulmonary edema. After delivery, liver dysfunction and a rapid decrease in platelet count were observed, and the patient was diagnosed with severe HELLP syndrome. She experienced multiple organ failure despite intensive care, and PE therapy was initiated. Her general condition dramatically stabilized within a few hours of PE therapy. CONCLUSION: It is controversial whether PE therapy should be used primarily in the management of HELLP syndrome, but early initiation of PE therapy could be effective for severe HELLP syndrome.

Correlation between Mean Arterial Pressure and Regional Cerebral Oxygen Saturation on Cardiopulmonary Bypass in Pediatric Cardiac Surgery.

Some pediatric cardiac patients might experience low regional cerebral oxygen saturation (rSO2) during surgery. We investigated whether a pediatric patient's mean arterial pressure (MAP) can affect the rSO2 value during cardiopulmonary bypass (CPB). We retrospectively analyzed the cases of the pediatric patients who underwentcardiac surgery at our hospital (Jan. -Dec. 2019; n=141). At each MAP stage, we constructed line charts through the mean of the rSO2 values corresponding to each MAP and then calculated the correlation coefficients. We next divided the patients into age subgroups (neonates, infants, children) and into cyanotic congenital heart disease (CHD) and acyanotic CHD groups and analyzed these groups in the same way. The analyses of all 141 patients revealed that during CPB the rSO2 value increased with an increase in MAP (r=0.1626). There was a correlation between rSO2 and MAP in the children (r=0.2720) but not in the neonates (r=0.06626) or infants (r=0.05260). Cyanotic CHD or acyanotic CHD did not have a significant effect on the rSO2/MAP correlation. Our analysis demonstrated different patterns of a correlation between MAP and rSO2 in pediatric cardiac surgery patients, depending on age. MAP was positively correlated with rSO2 typically in children but not in neonate or infant patients.

Temporary hypotension and ventilation difficulty during endoscopic injection sclerotherapy for esophageal varices in a child with Fontan circulation: a case report.

BACKGROUND: Endoscopic procedures are rarely performed in children with congenital heart disease (CHD); therefore, the associated complications are unknown. We report an abrupt change in circulatory and respiratory condition during endoscopic injection sclerotherapy for esophageal varices. CASE PRESENTATION: A 9-year-old boy with a history of total anomalous pulmonary venous connection (TAPVC) repair and Fontan procedure for asplenia and a single ventricle with TAPVC underwent endoscopic injection sclerotherapy under general anesthesia for esophageal varices. Systolic blood pressure decreased from 70 to 50 mmHg following a sclerosant injection; a second injection reduced his peripheral oxygen saturation from 93 to 79% secondary to ventilation difficulty. Although we suspected anaphylaxis intraoperatively, postoperative imaging suggested that balloon dilation performed to prevent sclerosing agent leakage caused compression of the pulmonary venous chamber and trachea owing to the anomalous intrathoracic organ anatomy. CONCLUSION: Thorough understanding of the complex anatomy is important before performing endoscopic procedures in children with CHD to preoperatively anticipate possible intraoperative complications and select the optimal therapeutic approach and anesthesia management.

Vascular occlusion with 0.035-inch hydrogel expandable coils in congenital heart diseases and vascular anomalies.

BACKGROUND: We present our experience with transcatheter vascular occlusion using 0.035-inch hydrogel expandable coils, which has been reported only in a few cases in the pediatric cardiology fields. METHODS: This study is a retrospective analysis of all patients who underwent transcatheter embolization with 0.035-inch hydrogel coils at the Department of Pediatrics, Okayama University Hospital, between October 2018 and September 2020. RESULTS: Twenty patients with a median age of 5.1 years (0.05-26.0 years) and a median weight of 13.8 kg (3.0-56.8 kg) were included. A total of fifty-four 0.035-inch hydrogel coils, including 35 Azur 35 and nineteen Azur CX 35 coils (Terumo, Tokyo, Japan), were successfully deployed in 22 target vessels. The target vessels consisted of 10 aortopulmonary collaterals, 8 veno-venous collaterals, and 4 pulmonary arteriovenous malformations. We achieved technical success in all the target vessels. In total, the mean target vessel diameter was 4.4 mm, the mean number of 0.035-inch hydrogel coils was 2.5 per vessel. The mean device to vessel ratio was 1.6 for the anchor coil and 1.2 for the additional coil. Post-implantation angiograms revealed that the primary occlusion rate was 18/22 (82%). There were no periprocedural complications. CONCLUSIONS: The 0.035-inch hydrogel expandable coils are effective and safe in patients with congenital heart disease and vascular anomalies. These occlusion devices could be valuable options for interventional pediatric cardiologists.

The frequency of postoperative BNP measurement and intervention threshold of BNP concentration in pediatric cardiac intensive care unit: a prospective multicenter observational study.

PURPOSE: The purpose of this study is to investigate the current status of postoperative BNP measurement in the pediatric cardiac intensive care unit (PCICU). METHODS: This was a prospective multicenter observational study. Children under 15 years old who underwent pediatric cardiac surgery were included. Postoperatively, all BNP measurement was collected in PCICU. We checked whether each BNP measurement was used for the decision-making of intervention or not. We divided the BNP measurements into 4 groups: group A 0-299 pg/ml (reference), group B 300-999 pg/ml, group C 1000-1999 pg/ml, group D ≧ 2000 pg/ml. We performed logistic regression analysis to compare the intervention ratio between group A and B, C, D. We also did multiple comparison analyses to compare the intervention ratio in each group. RESULTS: Thirty-nine (15.8%) measurements were used as a criterion to intervene in all BNP measurements. There was no protocol for the measurement of BNP in all institutions. The number of BNP measurements in each group is as follows: group A 113 (45.9%), group B 81 (32.9%), group C 45 (18.3%), group D 7 (2.8%). The intervention ratio in each group was 6.2% (group A), 8.6% (group B), 44.4% (group C), and 71.4% (group D). The intervention ratio of group C and D were significantly higher than group A: (Odds ratio (95%CI): 12.1(4.8-33.9), p < 0.0001, 25.2(5.2-146.2), p < 0.0001). The result of multiple comparisons is similar to logistic regression analysis. CONCLUSION: High BNP concentration, especially more than 1000 pg/ml, was more often intervened upon compared to that of less than 1000 pg/ml.

Stepwise Treatment for Heterotaxy Syndrome and Functional Single Ventricle Complicated by Infra-Cardiac Total Anomalous Pulmonary Venous Connection with Ductus Venosus Stent Placement and Subsequent Occlusion.

Even today, when the surgical outcome of congenital heart disease in the neonatal period has improved, the prognosis for heterotaxy syndrome and functional single ventricle complicated with total anomalous pulmonary venous connection (TAPVC), especially the infra-cardiac type, is catastrophic. We describe a strategy that combines percutaneous ductus venosus (DV) stent placement and occlusion after TAPVC repair to ensure survival from initial surgery to bidirectional cavopulmonary shunt (BCPS) procedure and facilitate subsequent treatment. Three consecutive patients with heterotaxy syndrome and functional single ventricle complicated by infra-cardiac TAPVC treated with our own strategy were retrospectively studied. In two infants, DV stent placement was performed on the day of birth. In one case at 11 days of age. The risk of pulmonary vein obstruction was reduced, and on-pump surgery, including TAPVC repair, was performed on a standby basis. Since the rapid increase in hepatic enzymes occurred on postoperative day 0 to 1 in all cases, percutaneous stent occlusion was performed until postoperative day 3. The procedure improved liver function. One patient died due to severe atrioventricular valve regurgitation, one case underwent BCPS, and one patient was waiting to undergo. DV stent placement can avoid TAPVC repair in the early neonatal period. After TAPVC repair, the portosystemic shunt remained, resulting in hepatic dysfunction, but this could be improved by stent and vertical vein occlusion. A series of stepwise treatments can be useful to help such critically ill infants survive the high-risk neonatal period and achieve good BCPS circulation.

Intact survival from severe cardiogenic shock caused by the first attack of atrial tachycardia treated with extracorporeal membrane oxygenation and surgical left atrium appendage resection: a case report.

BACKGROUND: Atrial tachycardia (AT) is rare in children and can usually be reversed to sinus rhythm with pharmacotherapy and cardioversion. We report a rare case of severe left-sided heart failure due to refractory AT. CASE PRESENTATION: A 12-year-old boy had AT with a heart rate of 180 beats/minute, which was refractory to any medication and defibrillation despite the first attack. Due to rapid cardiorespiratory collapse shortly after arriving at our hospital, central extracorporeal membrane oxygenation (ECMO) with left arterial venting was started immediately. Although AT persisted after that, it stopped on the 3rd day after admission following surgical resection of the left atrial appendage thought to be the source of AT. He was weaned off ECMO on the 7th day and ventilator on the 14th day. CONCLUSIONS: The appropriate timing of central ECMO and surgical ablation were effective in saving this child from a life-threatening situation caused by refractory AT.

Higher preoperative Qp/Qs ratio is associated with lower preoperative regional cerebral oxygen saturation in children with ventricular septal defect.

PURPOSE: The relationship between regional cerebral oxygen saturation (rSO2) and the amount of left-to-right shunt in ventricular septal defect (VSD) patients has not yet been investigated. The purpose of this study was to identify the association of preoperative pulmonary to systemic blood flow (Qp/Qs) ratio and preoperative rSO2 in patients with VSD. METHODS: We retrospectively evaluated 49 VSD surgical closure candidates at a single institution. Preoperative Qp/Qs ratio was compared with rSO2 measurements at the time of VSD closure surgery. RESULTS: Forty-nine were eligible for the final analysis. The median age at surgery was 6 (interquartile range [IQR]: 3, 12) months, and 36.7% were male. Atrial septal defects coexisted in 51.0%. There were no genetic abnormalities except trisomy 21 in 32.6% of the patients. Pulmonary hypertension was found in 42.8%. The median Qp/Qs ratio, calculated based on catheter testing results before the surgery, was 2.7 (IQR: 2.1, 3.7). Postoperative rSO2 was significantly higher than preoperative values (52.2 ± 12.9, 63.5 ± 13.1%, p < 0.001). There was an inverse relationship of Qp/Qs and preoperative cerebral rSO2 (r = - 0.11, p = 0.02). CONCLUSION: A higher Qp/Qs ratio was associated with a lower preoperative cerebral rSO2 in pediatric patients with VSD.

Integrated pulmonary index can predict respiratory compromise in high-risk patients in the post-anesthesia care unit: a prospective, observational study.

BACKGROUND: Respiratory compromise (RC) including hypoxia and hypoventilation is likely to be missed in the postoperative period. Integrated pulmonary index (IPI) is a comprehensive respiratory parameter evaluating ventilation and oxygenation. It is calculated from four parameters: end-tidal carbon dioxide, respiratory rate, oxygen saturation measured by pulse oximetry (SpO2), and pulse rate. We hypothesized that IPI monitoring can help predict the occurrence of RC in patients at high-risk of hypoventilation in post-anesthesia care units (PACUs). METHODS: This prospective observational study was conducted in two centers and included older adults (≥ 75-year-old) or obese (body mass index ≥ 28) patients who were at high-risk of hypoventilation. Monitoring was started on admission to the PACU after elective surgery under general anesthesia. We investigated the onset of RC defined as respiratory events with prolonged stay in the PACU or transfer to the intensive care units; airway narrowing, hypoxemia, hypercapnia, wheezing, apnea, and any other events that were judged to require interventions. We evaluated the relationship between several initial parameters in the PACU and the occurrence of RC. Additionally, we analyzed the relationship between IPI fluctuation during PACU stay and the occurrences of RC using individual standard deviations of the IPI every five minutes (IPI-SDs). RESULTS: In total, 288 patients were included (199 elderly, 66 obese, and 23 elderly and obese). Among them, 18 patients (6.3 %) developed RC. The initial IPI and SpO2 values in the PACU in the RC group were significantly lower than those in the non-RC group (6.7 ± 2.5 vs. 9.0 ± 1.3, p < 0.001 and 95.9 ± 4.2 % vs. 98.3 ± 1.9 %, p = 0.040, respectively). We used the area under the receiver operating characteristic curves (AUC) to evaluate their ability to predict RC. The AUCs of the IPI and SpO2 were 0.80 (0.69-0.91) and 0.64 (0.48-0.80), respectively. The IPI-SD, evaluating fluctuation, was significantly greater in the RC group than in the non-RC group (1.47 ± 0.74 vs. 0.93 ± 0.74, p = 0.002). CONCLUSIONS: Our study showed that low value of the initial IPI and the fluctuating IPI after admission to the PACU predict the occurrence of RC. The IPI might be useful for respiratory monitoring in PACUs and ICUs after general anesthesia.

Perioperative Milrinone Infusion Improves One-Year Survival After the Norwood-Sano Procedure.

OBJECTIVES: The aim of this study was to investigate whether milrinone infusion improved one-year survival in patients who underwent the Norwood-Sano procedure. DESIGN: A retrospective observational study. SETTING: A single-institution university hospital. PARTICIPANTS: Children who underwent the Norwood-Sano procedure from January 2008 to December 2014. INTERVENTIONS: Patients were categorized into two groups: group E+D, who received routine epinephrine and dopamine infusion, and group M, who received routine milrinone infusion for intra- and postoperative inotropic support. MEASUREMENTS AND MAIN RESULTS: The primary outcome of this study was one-year survival after the Norwood-Sano procedure. A total of 45 patients were included (group E+D, 22; group M, 23). One-year survival in group M was significantly higher than that in group E+D (95.7% [22/23] v 72.7% [16/22], p = 0.03). A Kaplan-Meier curve also showed that one-year survival in group M was significantly higher than that in group E+D (p = 0.04), from the result of the log-rank test. The number of patients who had any arrhythmias in the intensive care unit (ICU) was significantly lower in group M than in group E+D (21.7% [5/23] v 50% [11/22], p = 0.03). The duration of ICU stay did not have statistical difference between groups (group M 19; interquartile range [IQR], 15-28) v group E+D 19.5 (IQR, 16.3-35.5) days, p = 0.57). CONCLUSIONS: Perioperative milrinone infusion improved the mortality after the Norwood-Sano procedure. Potential advantages of milrinone compared with epinephrine are fewer arrhythmias and better systemic perfusion, which could decrease lethal cardiac events in the ICU.