Bilateral remote ischemic conditioning in children: A two-center, double-blind, randomized controlled trial in young children undergoing cardiac surgery.

Objective: The study objective was to determine whether adequately delivered bilateral remote ischemic preconditioning is cardioprotective in young children undergoing surgery for 2 common congenital heart defects with or without cyanosis. Methods: We performed a prospective, double-blind, randomized controlled trial at 2 centers in the United Kingdom. Children aged 3 to 36 months undergoing tetralogy of Fallot repair or ventricular septal defect closure were randomized 1:1 to receive bilateral preconditioning or sham intervention. Participants were followed up until hospital discharge or 30 days. The primary outcome was area under the curve for high-sensitivity troponin-T in the first 24 hours after surgery, analyzed by intention-to-treat. Right atrial biopsies were obtained in selected participants. Results: Between October 2016 and December 2020, 120 eligible children were randomized to receive bilateral preconditioning (n = 60) or sham intervention (n = 60). The primary outcome, area under the curve for high-sensitivity troponin-T, was higher in the preconditioning group (mean: 70.0 ± 50.9 µg/L/h, n = 56) than in controls (mean: 55.6 ± 30.1 µg/L/h, n = 58) (mean difference, 13.2 µg/L/h; 95% CI, 0.5-25.8; P = .04). Subgroup analyses did not show a differential treatment effect by oxygen saturations (pinteraction = .25), but there was evidence of a differential effect by underlying defect (pinteraction = .04). Secondary outcomes and myocardial metabolism, quantified in atrial biopsies, were not different between randomized groups. Conclusions: Bilateral remote ischemic preconditioning does not attenuate myocardial injury in children undergoing surgical repair for congenital heart defects, and there was evidence of potential harm in unstented tetralogy of Fallot. The routine use of remote ischemic preconditioning cannot be recommended for myocardial protection during pediatric cardiac surgery.

Bilateral Remote Ischaemic Conditioning in Children (BRICC) trial: protocol for a two-centre, double-blind, randomised controlled trial in young children undergoing cardiac surgery.

INTRODUCTION: Myocardial protection against ischaemic-reperfusion injury is a key determinant of heart function and outcome following cardiac surgery in children. However, with current strategies, myocardial injury occurs routinely following aortic cross-clamping, as demonstrated by the ubiquitous rise in circulating troponin. Remote ischaemic preconditioning, the application of brief, non-lethal cycles of ischaemia and reperfusion to a distant organ or tissue, is a simple, low-risk and readily available technique which may improve myocardial protection. The Bilateral Remote Ischaemic Conditioning in Children (BRICC) trial will assess whether remote ischaemic preconditioning, applied to both lower limbs immediately prior to surgery, reduces myocardial injury in cyanotic and acyanotic young children. METHODS AND ANALYSIS: The BRICC trial is a two-centre, double-blind, randomised controlled trial recruiting up to 120 young children (age 3 months to 3 years) undergoing primary repair of tetralogy of Fallot or surgical closure of an isolated ventricular septal defect. Participants will be randomised in a 1:1 ratio to either bilateral remote ischaemic preconditioning (3×5 min cycles) or sham immediately prior to surgery, with follow-up until discharge from hospital or 30 days, whichever is sooner. The primary outcome is reduction in area under the time-concentration curve for high-sensitivity (hs) troponin-T release in the first 24 hours after aortic cross-clamp release. Secondary outcome measures include peak hs-troponin-T, vasoactive inotrope score, arterial lactate and central venous oxygen saturations in the first 12 hours, and lengths of stay in the paediatric intensive care unit and the hospital. ETHICS AND DISSEMINATION: The trial was approved by the West Midlands-Solihull National Health Service Research Ethics Committee (16/WM/0309) on 5 August 2016. Findings will be disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Parents will be informed of the results through a newsletter in conjunction with a local charity. TRIAL REGISTRATION NUMBER: ISRCTN12923441.

Anesthetic management of gastrochisis--a review of our practice over the past 5 years.

BACKGROUND: Surgical closure of gastrochisis has traditionally been performed under general anesthesia followed by admission to intensive care and postoperative ventilation. We reviewed the management of these neonates in our hospital over the past 5 years to identify changes in practice and possible factors which affect the perioperative course. METHODS: We retrospectively identified cases of gastrochisis undergoing repair from June 2002 to May 2007. Details of the demographic data, preoperative factors, intraoperative anesthetic and surgical management and postoperative care were collected from the anesthetic chart, operative record and patient notes. RESULTS: Forty-eight self-ventilating neonates underwent operative repair in theatre. A neuraxial local anesthetic block was performed as part of the anesthetic technique in 22 patients. There was a significant difference in the need for postoperative ventilation in this group (23%) when compared with a traditional opioid-based method of providing analgesia (88%, P < 0.05). This difference was seen in both term and preterm babies. CONCLUSION: Conclusions are difficult when analyzing retrospective data in patients with a variety of factors. The results suggest that anesthesia which includes a regional technique is a valid method in these cases. Traditional opioid analgesia when compared to regional techniques may be associated with increased need for postoperative ventilation.

Anaesthetic management of gastroschisis - a review of our practice over the past 5 years.

BACKGROUND: Surgical closure of gastrochisis has traditionally been performed under general anesthesia followed by admission to intensive care and postoperative ventilation. We reviewed the management of these neonates in our hospital over the past 5 years to identify the changes in practice and possible factors which affect the peri-operative course. METHODS: We retrospectively identified cases of gastrochisis undergoing repair from June 2002 to May 2007. Details of the demographic data, preoperative factors, intra-operative anesthetic and surgical management, and postoperative care were collected from the anesthetic chart, operative record, and patient notes. RESULTS: Forty-eight self-ventilating neonates underwent operative repair in theatre. A neuraxial local anesthetic block was performed as part of the anesthetic technique in 22 patients. There was a significant difference in the need for postoperative ventilation in this group (23%) when compared with a traditional opioid-based method of providing analgesia (88%, P < 0.05). This difference was seen in both term and preterm babies. CONCLUSION: Conclusions are difficult to make when analyzing retrospective data in patients with a heterogeneous variety of factors. The results suggest that anesthesia which includes a regional technique is a valid method in these cases. Traditional opioid analgesia when compared with regional techniques may be associated with increased need for postoperative ventilation.