RESUMO
Background: Junctional ectopic tachycardia (JET) is the most common arrhythmia after pediatric open-heart surgeries (OHS), causing high morbidity and mortality. As diagnosis is often missed in patients with minimal hemodynamic instability, its incidence depends on active surveillance. A prospective randomized trial evaluated the efficacy and safety of prophylactic amiodarone and dexmedetomidine to prevent and control postoperative JET. Methods: Consecutive patients aged under 12 years were randomized into amiodarone, dexmedetomidine (initiated during anesthetic induction) and control groups. Outcome measures included incidence of JET, inotropic score, ventilation, and intensive care unit (ICU) duration and hospital stay, as well as adverse drug effects. Results: Two hundred and twenty-five consecutive patients with a median age of 9 months (range 2 days-144 months) and a median weight of 6.3 kg (range 1.8 kg-38 kg) were randomized with 70 patients each to amiodarone and dexmedetomidine groups, and the rest were controls. Ventricular septal defect and Fallot's tetralogy were the common defects. The overall incidence of JET was 16.4%. Syndromic patients, hypokalemia, hypomagnesemia, longer bypass, and cross-clamp duration were the risk factors for JET. Patients with JET had significantly prolonged ventilation (P = 0.043), longer ICU (P = 0.004), and hospital stay (P = 0.034) than those without JET. JET was less frequent in amiodarone (8.5%) and dexmedetomidine (14.2%) groups compared to controls (24.7%) (P = 0.022). Patients receiving amiodarone and dexmedetomidine had significantly lower inotropic requirements, lower ventilation duration (P = 0.008), ICU (P = 0.006), and hospital stay (P = 0.05). Adverse effects such as bradycardia and hypotension after amiodarone and ventricular dysfunction after dexmedetomidine were not significantly different from controls. Conclusion: Prophylactic amiodarone or dexmedetomidine started before OHS is effective and safe for the prevention of postoperative JET.
RESUMO
AIMS: To outline the etiology, clinical course, short-term survival to discharge and neurological outcome of infants (<1 yr) with new cardiac diagnoses presenting to a pediatric intensive care (PICU) unit with acute cardiac compromise. METHODS: Retrospective search of a computerized database and medical case notes for all acute cardiac admissions to PICU from June 2001 to 2006. Pre-existing hospital-based patients with new cardiac diagnoses were excluded. RESULTS: Seventy patients were identified, 38 (54%) of whom were male. There were six main subgroups: obstructive left heart lesions (n= 20), transposition of the great arteries (TGA) (n= 9), total anomalous pulmonary venous drainage (TAPVD) (n= 7), dilated cardiomyopathy (n= 11), arrhythmia (n= 12), and others (n= 11). Fifty-nine patients (84%) were external referrals to our center. The median age at presentation was 13.5 days (0-272) with median duration of symptoms of 1 day (0-21). The median base deficit at presentation was -7.6 mEq/L (-43 to +4.2). Fifty-three patients (76%) required respiratory support with a median duration of ventilation of 4 days (1-49). Fifty-six patients (80%) required inotropic support. The median PICU stay was 7 days (1-64) with a median total hospital stay of 16 days (1-71). Six patients (9%) died prior to discharge. Of the survivors 7 (11%) had seizure activity or evolving clinical neurological abnormalities. CONCLUSIONS: Cardiovascular compromise due to previously unrecognized congenital or acquired heart disease is associated with clinically significant morbidity and mortality. Longer term follow-up is required to evaluate the initial effect of poor cardiac output and hypoxia on long-term neurodevelopmental outcome.
