Background

Near infra-red spectroscopy (NIRS) is an exciting non-invasive, portable, continuous modality used to assess regional tissue oxygen saturations, expressed as a percentage. The use of NIRS in clinical practice is relatively recent, with its role in measuring cerebral oxygenation originally described in the 1970s.

Objectives

This review sets out the evidence behind the use of NIRS in the Paediatric Intensiva Care Unit.

Methods

A literature review was performed using search terms: NIRS,NIRS AND Paediatrics, NIRS AND Pediatrics, near-infrared spectroscopy AND paediatrics, near-infrared spectroscopy AND pediatrics.

All types of study/case report/review articles in English were included.

Results

The diagnosis of LCOS is currently made based on a number of clinical parameters.

Averaged cerebral and renal NIRS <65% predict a lactate >3mmol/L with a sensitivity of 95% and a specificity of 83% (p=0.0001, AUC 0.92).

NIRS can detect the redistribution of blood flow occurring as a physiological response to low cardiac output states, assessed by analysing the difference between somatic (flank) and cerebral NIRS. A NIRS difference between somatic and cerebral NIRS of 10% is significant (p<0.001).

NIRS also provides a robust indicator of renal dysfunction with an increased risk of doubling the creatinine level every hour the renal NIRS is <60% (p<0.001).

Lower cerebral NIRS post bypass is associated with a lower psychomotor development index (PDI) of the Bayley Scales and haemosiderin foci on MRI. Receptive communication may also be affected by the NIRS nadir.

Conclusion

Near-infrared spectroscopy is an exciting development in medical technology providing continuous, real-time, non-invasive monitoring which allows early intervention and reduced morbidity.

Background

At present, mean blood pressure (MBP) ranges for children are based on American reference tables. However, these reference values are based on a mixture of invasive and non-invasive blood pressure measurements in a small sample, irrespective of postconceptional age, weight and medications.

Objectives

Therefore, we aim to define non-invasive MBP reference values for neonates in various age groups.

Methods

In a retrospective database study, we selected all neonates admitted to a Dutch tertiary pediatric hospital between 2016-2018 with exclusion of severe comorbidities (major cardiac malformations, intracerebral hemorrhage, and intubation longer than 6h). We defined the median (P50) for the first week of life for MBP sorted per GA group and analyzed using the statistical package Generalized Additive Models for Location, Scale and Shape (GAMLSS) in the R.

Results

A total of 736 patients (61%), with 7128 measurements, fulfilled the inclusion criteria. 133 neonates were born below 29 weeks, 233 between 30-33 weeks, 187 between 34-37 weeks and 172 between 38-41 weeks. The P50 in the first weeks after birth increased from 30 mm Hg to 40 mm Hg in the youngest and from 49 mm Hg to 58 mm Hg in the oldest age group. Figures with reference values (P5, P50, P95) for age groups will be presented at the conference.

Conclusion

The presented reference values for non-invasive MBP in neonates at various age groups can be used to guide clinical decision making in healthy and diseased neonates at various age groups.

Background

Patent ductus arteriosus (PDA) is a frequent cardiovascular problem in preterm infants.

Objectives

The goal of this study was to evaluate the management and outcomes of hemodynamically significant PDA (HS-PDA) in a level 3 Neonatal Intensive Care Unit (NICU) and to identify possible risk factors and associated morbidities.

Methods

A retrospective study including all newborns (NB) < 30 weeks of gestation admitted with PDA and a comparative study between HS and non-HS PDA was conducted. Data were collected from clinical records between January 2010 and December 2018.

Results

A total of 143 NB was found, 103 HS-PDA and 40 non-HS-PDA.

In 6.8% HS-PDA was managed exclusively with fluid restriction while 93,2% needed medical or surgical (n=9) treatment.

HS-PDA was more frequent in extreme preterm infants (p=0.03) and in NB needing endotracheal intubation in resuscitation at birth (p<0.001).

Respiratory distress syndrome (p=0.006), surfactant administration (p<0.001) and mechanical ventilation > 7 days (p<0.001) were higher in the HS-PDA group

Anemia with transfusion criteria (p=0,014), intra-periventricular hemorrhage (p=0.019) and acute renal injury (p=0.003) were more common in the HS-PDA group.

Hospitalization for >100 days (p=0,039) and mortality (p=0.019) were higher in HS-PDA group.

At the six-month follow up, 2 HS-PDA were referred for surgical ligation.

Conclusion

Immaturity per se, as expected, was associated with HS-PDA with a higher incidence in extreme preterm infants.

In this study, most of the cases were managed with medical treatment.

HS-PDA was associated with worse clinical outcomes leading to higher mortality rates in preterm infants.

Background

Use of nitric oxide in preterm infants is controversial. Even though there is no good evidence, the use of nitric oxide has increased significantly in preterm population over the last decade.

Objectives

To review survival and neurodevelopmental outcome of preterm infants requiring nitric oxide in a tertiary Neonatal Intensive Care Unit.

Methods

Retrospective observational study over 10 year period from Jan 2009 to Dec 2018. Preterm infants needing Nitric oxide for pulmonary hypertension were recruited to the study. All data was collected from Badger (neonatal patient database). Neurodevelopmental outcomes of the survivors were analysed by Bayley’s III scale.

Results

7406 preterm infants <36 weeks were admitted to NICU during study period. 35 needed nitric oxide for pulmonary hypertension. Median gestation was 30+5 (25+2 to 36+1) weeks. Median birth weight was 1635 g (630g to 3380g). 21 (60%) were males and 14 (40%) were females. Echocardiography findings were available for 21 cases (60%) of which 71.4% had confirmed evidence of pulmonary hypertension. Severe respiratory distress syndrome was the leading cause for pulmonary hypertension. Overall survival to discharge was 68.5%.

Neurodevelopmental outcome was available for 15 babies of which 46.6% had a normal neurodevelopment. 26.6% were mildly delayed, 20% were moderately delayed and only 6.6% had severe delay.

Conclusion

The usage of nitric oxide in preterm infants is still very small. Nearly 73% had normal or mild developmental delay. Careful selection of cases is required by echocardiography to improve the outcomes.

Background

Patent ductus arteriosus (PDA) is a common finding in newborns (NB), especially in extreme preterm infants. There are few publications about the impact and approach of this condition in infants > 28 weeks of gestation.

Objectives

Verify the management and impact of PDA in preterm infants > 30 weeks of gestation and term neonates.

Methods

A retrospective study including all NB ≥ 30 weeks of gestation admitted to a level 3 Neonatal Intensive Care Unit with PDA was conducted. Data were collected from clinical records between January 2010 and December 2018. NB with congenital cardiopathy were excluded.

Results

The final sample of 105 NB was divided in two groups:

30 to 33 weeks + 6/7 days (n=64): In 48.4% of the cases echocardiography was performed due to a heart murmur. A hemodynamically significant PDA (HS-PDA) was found in 22 cases and 13 were treated with ibuprofen. At the time of hospital discharge 32 maintained a restrictive PDA compared with only 2 cases at the 6-month follow-up review.

Late preterm and term NB (n=41): Echocardiography was performed mainly due to a heart murmur (41.5%), prenatal suspicion of cardiac anomalies (14.6%) or clinical deterioration (12.2%). HS-PDA was found in 7 cases, one treated with ibuprofen. At the 6-month follow-up review 2 patients maintained a restrictive PDA while 2 needed surgical ligation.

Conclusion

In moderate and late preterm and in term infants HS-PDA mainly presents with a heart murmur. This condition is usually managed with fluid restriction leading to a good clinical outcome.

Background

The incidence of PDA in<28weeks babies is 75%

Objectives

To review the medical management of PDA in extreme preterm babies born at early gestation of viability at 23 weeks in a tertiary Neonatal unit in UK.

Methods

All babies born at 23+0 to 23+6 weeks were included during the study period(Jan 2010- Dec 2014).Data was collected about PDA diagnosis and management from the medical notes and local neonatal database.Significant PDA was defined as on Echo: Duct size >1.5mm,left heart dilatation La:Ao (Left atrium:Aortic) ratio: >1.4,Pulsatile ductal flow pattern,Velocity max>2mm/s,diastolic retrograde flow in descending aorta. Ibuprofen was only drug used for medical management of PDA.

Results

21 babies born during the study period were reviewed,4 babies died before ECHO at age<24 hours,constituting 17 babies in the study. Mean PDA detection was at 5.5 days.Average PDA size was 2 mm(+/- 0.78 SD), significant duct size was measured in 82 % (14/17). Average LA-Ao ratio was 1.4(0.30 SD) and significant in 47%.10 babies required Ibuprofen treatment and 7 did not require and the mean age was 5.8 days for administering it.8 babies required 1 course (Dose 10, 5, 5 mg) and 2 babies required 2 courses,1 of which required surgical ligation.Treatment associated effects of altered renal functions and NEC in 1 baby each and thrombocytopenia in 2 babies.Other co-morbidities noted were IVH(9), CLD(11),NEC-confirmed(3).6/17 babies survived to discharge.

Conclusion

Medical management of PDA even from a single NICU is quite variable.The unit will be participating in a multicenter RCT to answer some of these uncertainties.

Background

Neonatal cardiomyopathy is a rare disease that ranges from asymptomatic to abruptly lethal. However, there are few studies regarding neonatal cardiomyopathy.

Objectives

We investigated the clinical features of five neonates with cardiomyopathy in our hospital.

Methods

We retrospectively reviewed the records of five newborns who were diagnosed with cardiomyopathy (three hypertrophic cardiomyopathy: HCM, one dilated cardiomyopathy: DCM, one left ventricular noncompaction: LVNC) between January 2004 and December 2018 inclusive. Primary evaluation items were reasons for reaching a diagnosis, underlying disease, therapy, and turning point.

Results

Patients with HCM and those with LVNC were diagnosed on the basis of cardiac murmur ; the patient with DCM was diagnosed on the basis of sucking failure. Underlying diseases were Noonan syndrome and LEOPARD syndrome. All patients had taken β-blockers, whereas those with DCM and LVNC had also taken diuretics and angiotensin-converting enzyme inhibitors. The three patients with HCM are undergoing follow-up as out-patients. The patient with DCM died due to progressed heart failure at 38 days after birth. The patient with LVNC had already exhibited severe heart failure after birth, and is now undergoing follow-up while heart transplantation is considered.

Conclusion

Because two patients with HCM exhibited Noonan syndrome and LEOPARD syndrome as RAS/MAPK-related diseases, this underlying conditions should be considered in patients who receive a diagnosis of HCM. Because heart failure progresses rapidly in patients with neonatal DCM and those with LVNC, planed therapy should include discussion of heart transplantation.

Background

We present a case of aorticopulmonary window (APW) with aortic arch interruptions that developed giant pseudoaneurysm after surgery.

Objectives

Case

A 6-day-old baby was referred to hospital for surgery with the diagnosis of APW. The patient was intubated and mechanical ventilation was performed due to respiratory distress. The echocardiographic evaluation showed a wide APW, patent ductus arteriosus, transverse aortic hypoplasia, aortic arch interruption and pulmonary hypertension.

Methods

Prostaglandin infusion was started. At 12 days of age, the hypoplastic transverse arch and interrupted aortic arch were repaired with prosthetic material. APW was repaired, PDA was ligated. Candida albicans was produced in the blood culture in the preoperative period. Antifungal therapy was initiated. The echocardiogram on the 18th postoperative day revealed giant pseudo aneurysm in the aortic arch. CT angiography showed a pseudo aneurysm extending from the aortic isthmus to distal descending aorta with active bleeding and hematoma in posterior mediastinum. The patient underwent to urgent surgery on the same day. Control CT angiographic evaluation revealed no aneurysm in the transverse aorta and descending aorta.

Results

He was discharged 21th day after the second operation. Blood culture taken 1 month after the end of antifungal treatment was negative

Conclusion

Aortopulmonary window (APW) may be an isolated anomaly (simple) or associated with concomitant cardiovascular anomalies (complex). Mortality is almost always due to concomitant cardiovascular anomalies. One of the most common concomitant cardiovascular anomalies is an interrupted aortic arch. Our patient underwent re-operation because of fungal end arthritis after a successful adjustment surgery.

Background

Pneumopericardium is a rare air-leak syndrome caused by abnormal presence of air in the pericardial space, with potentially high risk of morbidity and mortality. Clinically, it can be divided in non-tension and tension pneumopericardium, the latter resulting in a decreased cardiac output and circulatory failure. Scant data are available on non-traumatic tension pneumopericardium in non-ventilated patients.

Objectives

To describe a case of tension pneumopericardium and review the pertinent literature.

Methods

Case report and review of the literature (Pubmed search) of non-traumatic and non-ventilated pneumopericardium in children.

Results

Case: A 2-month-old infant developed cardiac tamponade due to tension pneumopericardium 11 days after cardiac surgery. The prompt treatment with pericardium drainage resolved the critical clinical conditions.

Literature review: 55 cases of pneumopericardium retrieved, a minority of which were tension pneumopericardium (17/55, 30.9%). Patients with tension pneumopericardium were predominantly males 12/16 (75.0%) with a mean age of 4.8 years. Most of the patients with non-tension pneumopericardium were children (21/38, 55.3%); patients with tension pneumopericardium were mainly newborns (6/17, 35.3%). The etiologies are reported in Figure 1. Conservative treatment was performed in all cases of non-tension pneumopericardium and pericardiocentesis in all other cases. Overall, the majority of the patients survived (41/51, 80.3%); with a lower survival rate among patients with tension pneumopericardium (62.5% vs 88.6%).

Conclusion

Pneumopericardium is a rare condition with a higher mortality rate in patients with tension pneumopericardium which requires immediate diagnosis and treatment. In non-ventilated patients tension pneumopericardium presents in younger ages, especially in patients with a history of surgery and leukemia.

Background

NIRS is widely used in paediatric cardiac surgery to monitor cerebral perfusion. It is increasingly used in the postoperative period, however there are no universally accepted guidelines on use and interpretation.

Objectives

We reviewed existing literature and designed a protocol in the CICU for NIRS monitoring and intervention. Our main objective was to determine if protocol-driven NIRS monitoring can help early recognition of haemodynamic instability and neurological compromise.

Methods

We designed algorithms for 3 distinct patient populations: 1) Bilateral cerebral monitoring for those supported on extracorporeal membrane oxygenation (ECMO) and 2) Cerebral and somatic (renal) monitoring in those post-cardiac surgery. Different NIRS targets and intervention thresholds were developed for the 2 post-operative patient groups: univentricular and biventricular physiology with incorporation of clinical, biochemical and imaging parameters that would help identify the cause for NIRS desaturation.

Results

The protocol was peer-reviewed and implemented after adequate staff training. While electronic data collection is ongoing, to date we identified one patient on ECMO who developed seizures and was found to have a unilateral intracranial bleed. The cerebral saturation was persistently low with a 20% drop on affected side with no change on the opposite side preceding the seizures by a few hours. Having a protocol has increased NIRS usage in a meaningful way for high-risk patients.

Conclusion

Use of NIRS is controversial given concerns regarding reliability and difficult interpretation with no published intervention algorithms. The algorithms that we have developed will help determine the potential usefulness of NIRS monitoring in the CICU.

Background

Advances in cardiac surgery over the last few decades, including corrective operations in early life, have dramatically increased the survival of children, particularly those with congenital heart disease.

Objectives

To describe the evolution of patients undergoing cardiac surgery in a Portuguese Paediatric Intensive Care Unit (PICU).

Methods

Retrospective study through databasis of children admitted in PICU in the postoperative period of cardiac surgery, from January 2017 to August 2018.

Results

There were 91 hospitalizations; one of the patients was hospitalized two times in this period. Of 90 patients, 54,4% were male, mean age was 4,27 years [1 month to 18 years]. In this population, 93,3% had congenital heart disease, the most frequent were ventricular and atrial septal defect and Fallot tetralogy; 42,9% had history of another comorbidities and 20,9% have made other cardiac surgeries in the past. Median time of surgery was 287,5 minutes [45-1083min]. In postoperative period, 64,8% were intubated and 27,5% had non-invasive ventilation, with mean duration of mechanical ventilation of 7,8 days. Vasoactive drugs were needed in 48,4% and pacing device in 15,4%; 2 patients needed cardioversion and other 2 patients needed ECMO support. Complications were seen in 50,5%, the most frequent were respiratory and hematologic, and 8,8% of patients required peritoneal dialysis. Deferred closure of the chest was made in 4,4% and 8,8% were reoperated, with one of this patients undergoing heart transplantation. Mortality rate was 2,2% in 20 months of study.

Conclusion

Children undergoing cardiac surgery constitute a high-risk population, justifying a multidisciplinary, differentiated and integrated approach.

Background

In general, evidence supports a beneficial impact of ECMO use in congenital cardiothoracic surgery. Applying ECMO for treatment in the non- cardiac, respiratory failure or septic child less frequent. The risks and benefits of ECMO therapy in the pediatric population are not clearly defined and clinicians continue to rely on pooled data from the ECLS registry and institutional experience when making decisions in individual cases.

Extracorporeal membrane oxygenation (ECMO) is usually reserved as a last resort for the treatment of sepsis, because sepsis was originally considered a contraindication to ECMO. Recent reports, however, have shown efficacy without increased mortality in septic pediatric patients undergoing ECMO. However, no evidence were found regarding long term use of ECMO- how many days, weeks and months can a child be viable on ECMO?

Objectives

To demonstrate long- term use of pediatric ECMO and its complications and ethical foundation.

Methods

Using a case report format the pro and cons of long-term (96 days) application of ECMO caring for a child. The baseline disease was unknown, the child is alive using ECMO and could not be weaned off. Should the tubing be replaced when clotted? This case will demonstrate a multi-disciplinary approach to ethical problem solving. The team included physicians, nurses, social workers, parents, grandparents, and spiritual leader. All viewpoints and perspectives were considered in final decision-making.

Conclusion

In this era of high tech PICU with advanced medical devices and the ability to sustain life for months, end of life and quality of life decisions are increasingly more difficult.

Background

Bronchiolitis is the most frequent cause of admission to the pediatric intensive care unit (PICU). Though extra-pulmonary manifestations have been previously studied, myocardial dysfunction has not yet been well defined.

Objectives

The aim of this study was to assess cardiac function in patients hospitalized with bronchiolitis.

Methods

Infants (0-12 months) hospitalized with bronchiolitis between January and March 2019 were included in this prospective, observational study. Previous cardiopathies were considered exclusion criteria. Echocardiography was performed within 48 hours of admission. Measurements of right ventricle (RV) and left ventricle (LV) systolic and diastolic function as well as cardiac output were analyzed. Data obtained were compared with healthy age-matched controls (n=22).

Results

Forty-three children were enrolled in the study (median age 3.6 months). Fifteen (34%) required admission to the PICU for positive pressure and three mechanical ventilation.

Patients requiring PICU support had significant RV systolic dysfunction, with diminished mean TAPSE (10.3±1.8 vs. 12.5±2, p=0.001) and s'tricuspid Tissue Doppler Index (TDI) values (8.9±2 vs. 10.4±1.6, p=0.029) compared with mild cases of bronchiolitis. LV diastolic dysfunction was also found in this group, with lower mean e'mitral TDI values (8.2±3.4 vs. 9.8±3.1, p=0.02) and increased E/e'mitral ratios (10.8±3.1 vs. 9.3±2.9, p=0.06). There were no significant differences between controls and patients with mild bronchiolitis.

Conclusion

In addition to expected RV systolic dysfunction, patients with severe bronchiolitis have altered LV diastolic function, possibly due to direct viral cardiac involvement. Confirmation of these results in further studies encompassing larger series could help optimize ICU hemodynamic management of severe bronchiolitis.