Children who suffer cardiopulmonary arrest (CPA) after cardiac surgery frequently survive with return of spontaneous circulation (ROSC). However, their neurodevelopmental outcomes and performance are still unclear.
The aim of this study is to evaluate the midterm neurodevelopmental and performance of children who survived CPA following cardiac surgery.
We followed up children who received CPR post cardiac surgery during 2012-2013. We assessed their 5 years survival, functional and neurodevelopmental outcomes using two performance scales: Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC). Both scales range from (1) for normal until (6) for brain death/death. We compared CPR group to a matching comparable group (1:1) that had no CPA or CPR.
15 out of 758 (2%) post-operative cardiac children, had 19 episodes of CPA. Median age was 10 months (0.5-168). Survival rates were 12/15 (80%) on hospital discharge and 10/15 (66%) after 5 years. Among 12 survivors, 2 patients (17%) scored 6, 1 (8%) scored 4, 5 (42%) scored 2, and 4 (33%) scored 1 on both PCPC and POPC. The median PCPC and POPC scores were (2, [interquartile range: 1 to 6] and 1, [interquartile range: 1 to 3], P= 0.018) for CPR and matching group respectively. Regression analysis identifies duration of CPR, number of CPR session and late occuring CPA as risk factors for poor outcome.
2/3 of children requiring CPR post cardiac surgery survived after 5 years. Neurodevelopmentally, they demonstrated worse outcome. CPR duration, number of CPA events and late CPA were risk factors for poor outcome.
The Berlin Heart VAD is powered by a stationary driving unit but a mobile unit is under development. Very little is known about parental attitudes to discharge home with VAD and no study has been conducted in children.
This study aimed to explore views of patients and families on the acceptability of hospital discharge, particularly on caring for a child on Berlin Heart EXCOR outside the clinical environment.
We undertook 24 interviews of transplanted patients (and/or family members) previously on a VAD and ethnographic observations of two current VAD patients. Inductive analysis was performed.
Families were hesitant to leave hospital with their child on VAD despite training, though some were more confident. Reasons went beyond responsibility for the VAD itself. EXCOR patients and families in particular feared a sudden emergency. Families valued private family time and three families with a child on EXCOR expressed willingness to care for their child in on-site private accommodation. The close observation needed, restrictions on freedom and care overnight were concerns. Psychological adjustment coincided often with family separation, financial constraints, and an inescapable fear. Children remembered boredom, pain and fear. Families would refuse discharge home if this meant moving from the urgent transplant list to the routine.
Families of children on the EXCOR did not seek discharge home but easier mobilisation and greater independence to enhance their hospital experience. Following training, home was an option for children on the Heartware VAD although parents’ main focus was a healthy speedy transplant.
Effect of continuous veno-venous hemofiltration (CVVH) on hemodynamic status and outcomes of children with fulminant myocarditis is unknown.
This study aimed to assess the effect of CVVH on hemodynamic, metabolic status, and outcome of fulminant myocarditis in children.
Thirty five children with fulminant myocarditis admitted to PICU of Vietnam National Children's Hospital from 2013 to 2018 were included. Conventional cardiogenic shock management was provided. CVVH was indicated using PrismaFlex machine (Gambro, Germany) with AN69 hemofilter membrane when hemodynamic endpoints of resuscitation protocol were not met and high doses of inotropes- vasopressors were required. Hemodynamic, metabolic parameters, and vasoactive-inotropic score (VIS) were recorded during CVVH. Survival was assessed at 28 days from PICU admission
Median time from ICU admission to therapy initiation was five hours. CVVH duration medians were 69.5 and 46.0 hours for survivors and non-survivors, respectively, and median ultrafiltration rate was 50 ml/kg per hour. After CVVH commenced, mean arterial blood pressure, pH, and central venous oxygen saturation (ScvO2) level increased while heart rate, VIS, and lactate level decreased significantly. Mean heart rate decreased from 174.9 ± 35.0 bpm at initiation to 157.0 ± 27.5 bpm at 12 hours after CVVH. Median VIS decreased from 54.3 at CVVH initiation to 7.5 at 48h after CVVH initiated. Among survivors, fraction ejection of left ventricles improved significantly after 48-72 h of CVVH. Mortality was 31.4%. Time interval from PICU admission to CVVH initiation was associated with survival.
Continuous veno-venous hemofiltration could improve hemodynamic status and outcome of children with fulminant myocarditis
Monitoring of the sublingual microcirculation (SMC) offers insight into tissue oxygenation. In contrast to findings in adults, it remains unclear whether children undergoing cardiac surgery on cardiopulmonary bypass (CPB) also show SMC alterations and thus altered tissue oxygenation.
To assess whether SMC is altered during the first 6h after cardiac surgery.
We performed a prospective observational study in a tertiary children’s hospital. Children aged 0–17 years undergoing cardiac surgery on CPB were eligible. SMC was monitored before and until 6h after surgery with handheld vital microscopy. Parameters of vessel density and perfusion were assessed for all vessels (diameter <100µm) and capillaries (<20µm). Mixed models were built to assess change over time and identify covariates.
Thirty-eight patients (median age 0.62 years (IQR: 3.06), 16 females, 20 cyanotic heart defects, frequency RACHS-1 categories 1-6: 6, 21, 9, 1, 0 and 1 respectively) were included. All patients survived. Microcirculatory flow index of capillaries (MFI<20µm), i.e. flow quality, decreased after surgery (2.8 (IQR: 0.4) to 2.5 (IQR: 0.6)) and did not improve 6h after surgery. Other SMC parameters were unaltered after surgery and did not change over time. SMC parameters did not differ between cyanotic and acyanotic heart defects. Perfused vessel density of capillaries was higher in neonates or males or if PaO2 increased. MFI<20µm was higher if RACHS-1 category >2, if mean arterial pressure increased or if pH or bleeding decreased.
Blood flow quality of capillaries was decreased during the first hours after cardiac surgery, a sign of otherwise unnoticed altered tissue oxygenation.