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Background and Aims

Patent ductus arteriosus (PDA) in preterm infants has been associated with significant morbidities. Current treatment methods have important drawbacks. We report on a novel treatment for catheter interventional closure of PDA in premature infants with ultrasound guidance only.

Methods

A method for transvenous percutaneous PDA closure in premature infants solely under echocardiographic guidance was developed. We used a step-by-step approach for moving away from the catheterization lab towards the referring NICU for the procedure.

Results

Fifteen premature infants were treated percutaneously for PDA with echocardiographic guidance only. Their weight ranged from 800 to 1550g. Only the femoral vein was used as vascular access. The first three patients were treated in the catheterization laboratory but without radiologic guidance, three in our pediatric cardiology ICU and the other nine in the NICU of the referring clinic in an incubator. Piccolo devices (Abbott medical, Plymouth, MN) were used. All patients survived. In one patient a residual shunt persisted for 3 weeks before spontaneous closure occurred. One patient lost transiently the femoral artery pulse on the contralateral site of the venous puncture and one had a possible thromboembolic event into the testicle. Another patient had a mild transient stenosis of the left pulmonary artery. There were no other complications.

Conclusions

The presented method enabled safe and effective percutaneous closure of the PDA in prematures solely under ultrasound guidance at the bedside. Further establishment of the technique should provide an optimal treatment method for PDA in extremely low birth weight infants.

Background and Aims

The ratio of splanchnic (StO₂s) to cerebral (StO₂c) tissue oxygen using near-infrared spectroscopy (NIRS) [Cerebrosplanchnic oxygenation ratio, (CSOR)] has been used as surrogate for splanchnic tissue oxygen status. Given the cerebral autoregulation, any decrease in CSOR is equated with splanchnic ischemia. The study aimed to examine the contribution of both cerebral and splanchnic oxygenation components to CSOR changes associated with Packed Red Blood Cell Transfusion (PRBCT).

Methods

In this prospective cohort study, haemodynamically stable infants: Gestation <32 weeks; birth weight <1500 grams; postmenstrual age <37 weeks: tolerating ≥120 mL/kg/day feeds, receiving PRBCT were enrolled. Transfusion-associated changes were determined by performing mixed models for repeated measures analysis between the 4-hour mean pre-transfusion value (CSOR, StO₂s and StO₂c) and each of the post-transfusion hourly mean values for the next 28 hours.

Results

Of 30 enrolled infants 14[46.7%] male; median[IQR] birth weight, 923[655-1064]g; gestation, 26.4[25.5-28.1]weeks; enrolment weight, 1549[1113-1882]g; and postmenstrual age, 33.6[32.4-35]weeks, 1 was excluded because of corrupted NIRS data. With commencement of PRBCT, CSOR demonstrated a downward trend throughout the study period. As compared to pre-transfusion, post-transfusion CSOR was significantly lower and StO₂c was significantly higher at several points along the post-transfusion period. However, post-transfusion StO₂s remained unchanged during the study.

Conclusions

Decrease in CSOR associated with PRBCT indicates improved cerebral rather than worsened splanchnic oxygenation. Our study underlines that it is necessary to determine absolute values of cerebral and splanchnic StO₂ to understand changes in CSOR. Furthermore, the results of this study suggest the utility of CSOR to determine splanchnic oxygenation to be unreliable.

Background and Aims

Even though many SGA newborn infants ‘are admitted to neonatal intensive care units, there are some who complete transition to extrauterine life without complication. The primary aim of this study was to characterize the cardiovascular performance during adaptation to extrauterine life in a group of SGA and AGA healthy newborns infants at 48 hours of age.

Methods

Prospective observational study was conducted in the postnatal ward at Targu Mures County Hospital, secondary care teaching hospital.

Results

We studied 57 neonates (31 males), born at a mean (SD) gestation of 37.7± 2.3 weeks with mean birth weight of 2.6± 0.7 kg. The median (IQR) Apgar score at 5 minutes of age was 9 (9, 9) and mean cord blood pH was 7.07± 0.8. We obtained echocardiography derived measures of pulmonary and systemic blood flow, cardiac function and shunts, cerebral and splanchnic perfusion within 48 hours of age. We observed for SGA infants decreased mean values of echocardiography-derived indices of RV systolic function TAPSE 7.9 (SD 1.2) versus 8.9 (SD 1.6), p= .05, but no statistically significant differences between groups for left ventricle systolic function, EF= 74.8 ±9.2 versus 68.6 ±10.8, p= .24.The proportions of infants with visible flow through PDA and PFO was not different between groups.

Conclusions

We found different values of hemodynamic indices of cardiovascular function among healthy SGA compare to AGA newborns. These differences may not be related with cardiovascular compromise but are worth to be validated in a population of interest before routine clinical use can be advocated.

Background and Aims

Red-blood cells (RBC) transfusions are common in paediatric intensive care units (PICU). Although a restrictive transfusion practice is currently recommended, most PICUs do not have a protocolized practice. The objective is to evaluate the indication of RBC transfusion in a PICU, its efficacy and to compare the outcomes with non-transfused patients.

Methods

Prospective longitudinal observational study in one tertiary PICU-CICU. Children admitted during one-year period who received at least one RBC transfusion were included. Patient’s demographics, pre and post-transfusion analytical and clinical parameters, outcomes and adverse effects were registered.

Results

68/351 19.4%) patients received a total of 249 transfusions (185 excluding ECMO patients). Mean age was 4.7±5.9 years. Main adminission diagnosis was cardiac surgery (Table-1). 60.6% had anaemia at admission (vs 36.5% in non-transfused, p=0.006). Transfusion was indicated with a median of 8.6±1.3 g/dl: > 7 g/dl in the 76.8% of non-cyanotic patients and > 9 g/dl in the 51% of cyanotic patients. After transfusion, Hb increased 2.3±1.2 g/dl 2h (p<0.0001); baseline ScvO₂ (58.3±15.8%) increased 6.2±11.3% (p<0.0001); oxygen extraction ratio decreased 0.09±0.14 (p=0.004), and lactate decreased 0.24±1.3 mmol/L (p=0.007). No direct adverse effects were found. Transfused patients had a length of stay of 29.2±42.5 vs 6.1±7.2 days in non-transfused (p<0.0001). Length of IMV was 27±49 vs 4.3±4.8 days (p=0.003). Mortality was 14.9% in transfused patients (vs 1.4%, p<0.0001).

Conclusions

A high percentage of children received RBC. Transfusions were indicated with higher Hb thresholds than internationally recommended. Patients who were transfused had unfavourable prognosis scores and worse outcomes.

Background and Aims

Unfractionated heparin (UH) remains the anticoagulant of choice due to its effectiveness, rapid onset of effect, easy inactivation and low cost. UH, being a heterogeneous substance including sulphated glycosaminoglycans with a molecular weight from 5,000 to 30,000 Da, has a variable “dose-effect” activity depending on the drug manufacturer. Heparinization assessment on ACT has a number of limitations. The aim of this study was to evaluate the rate of heparin resistance in pediatric cardiosurgical patients.

Methods

The study included 306 paediatric and neonatal patients who underwent open heart surgery. The hemostatic tests were PT, aPPT, FG, AT-III activity, ACT. The starting dose of heparin was 300 U/kg followed by repeated administration of 50-100 U/kg every 30-120 min to achieve the target values of activated clotting time >480 sec.

Results

There were 26 patients out of 306 (8.496%) who had heparin resistance and required additional bolus of heparin and AT-III infusion.

Most cases of heparin resistance are associated with low antithrombin levels and its activity and heparin pre-tretment.

Conclusions

ACT is not a specific marker of the heparin effectiveness and just correlates with its level. There are factors such as hemodilution, hypothermia, AT-III activity and heparin pre-treatment lead to increse heparin resistance rate. UH usage should be personalized according to age-specific standards.

Background and Aims

Necrotising enterocolitis (NEC) is a potentially fatal gut condition.^1. Risk factors in term infants include polycythaemia, asphyxia, and cardiac disease.² The rate of NEC in term infants is 0.07% ³ and 3-4% in paediatric cardiac intensive care globally, with significant morbidity and mortality. ^2,4,5 We describe the 10-year experience of a UK cardiac centre.

Methods

Electronic records from 2010-2020 were examined for evidence of NEC. Outcome, disease severity (with Bell criteria), underlying cardiac diagnosis, and other possible associations with NEC development were examined.

Results

Of 2212 cardiac admissions, 77 developed NEC (3.48%). NEC onset was between 2 days and 9 months. Bell criteria were evenly distributed (31% Stage 1, 34% Stage 2, 35% stage 3). Graphs show outcomes and possible associations.

Conclusions

NEC adds significant morbidity and mortality to this already high-risk group. Development of NEC is overrepresented in children with physiological evidence of low cardiac output or poor systemic perfusion (high inotrope dose, high lactate, low diastolic BP or prostaglandin use indicating duct-dependent perfusion). Premature and small babies are also overrepresented, as are children with postnatal cardiac diagnoses. Statistical analysis against a control group will be conducted to evaluate the proposed associations and provide a framework to anticipate NEC in this vulnerable group.

Background and Aims

Anemia is common in critically ill pediatric patients and is associated with adverse outcomes. The objective is to assess the prevalence and incidence of anemia in critically ill children, and to compare the outcomes of patients with and without anemia.

Methods

A prospective longitudinal observational study was performed in one tertiary PICU-CICU during 1-year period. All patients admitted were included except those without blood collection. Patient’s admission, progress and outcome data as well as anemia parameters were registered.

Results

289/311 patients were included, with a mean age of 5±5.4 years. Global main admission diagnosis was cardiac surgery (38.7%) followed by respiratory cause (20.6%) but cardiac surgery was the prevalent admission diagnosis in patients with anemia (46.6%) and non-anemic patients were admitted mostly due to respiratory reasons (35.8%), (Table 1). 42.2% had anemia at admission, which increase up to 79.2% in patients admitted after cardiac surgery (p<0.0001). 24.5% developed anemia during the stay. 56.5% presented anemia at discharged. Anemic patients had a length of stay of 15.02±28.3 vs 64.86±3.2 days in non-anemic (p<0.0001). Length of invasive mechanical ventilation was 18.39±39.8 vs 3.52±2.5 days (p=0.002). 10 patients with anemia died vs 3 non-anemic patients (p=0.17).

Conclusions

Anemia is a common condition in pediatric intensive care units and it is associated with worse outcomes. Practices to reduce anemia in critically-ill children must be a priority.

Background and Aims

Hemodynamic disorder is one the most problems in our pediatric intensive care unit (PICU). Ultrasound is routinely used to guide hemodynamic evaluation and management.

In this study, we aimed to identify hemodynamic profiles of children with ACF and his management

Methods

We conducted in this prospective monocentric observational cohort study between 01/01/2012 au 31/12/2017 in our PICU including children with ACF. All patients had a non invasive hemodynamic evaluation and management based on ultrasound

Results

ACF were found in 145 childrens with clinicals hypoperfusion signs: core-peripheral temperature gap in 95,8%, Capillary refill time (> 2 sec)
 81,4%, Mottled skin 48,9%, tachycardia in 21,8%, hypotension in (8, 3%), oliguria in (86,9%).

We identifed 3 hemodynamic profiles : hypovolemic (79,3%), vasoplegia (62%) and cardiogenic shok ( 27,5%). Ultrasound showed a left ventricular dysfunction in (63%) related to (adrenegic myocarditis in 52%, septic myocardiopathy in 44% and viral myocarditisin 5%) , right ventricular dysfunction with acute cor pulmonale in 32% and cardiac tamponade in 5%. Hemodynamic management showed significant gain of strok volume [(±20,0 5,6) %; p0,0001], with a mean volume loading of [(20,0±5,6ml/kg], a mean dose of norepinephrine of [(1,33±1,68) μg/kg/min] and a mean dose of dobutamine of [(7.48 ± 4.10) μg/kg/min].

Conclusions

In this study non invasive hemodynamic evaluation with ultrasound showed different hemodynamic profiles and allows hemodynamic improvement in children with ACF in PICU.

Background and Aims

To describe demographics, complication rates and outcomes of a single centre pediatric cohort undergoing cardiac surgery for congenital heart disease (CHD).

Methods

Records of children who underwent surgery for CHD from April 2020 to January 2021 were reviewed.

Results

119 consecutive paediatric patients (ages between 1 day and 18 years old) were evaluated, 71 of which (59.6%) were males. Median age was 1.5 years old (IQR 0.3-6.5) and median operative weight of 9.5 kg (IQR 4.5-24.5). 97 patients (81.5%) required cardiopulmonary bypass (CPB) with a median CPB time of 92 minutes (IQR 56-130). Aortic cross clamp was applied to 99 patients (83.2%) with a median duration of 45 minutes (IQR 26-79). 96 patients (80.7%) required inotropic or/and vasopressor support post-operatively. Most frequent complications included acute kidney injury (AKI) in 19 patients (15.9%), rhythm disturbances requiring antiarrhythmics and/or external pacing (n=8), development of chylothorax (n=5) and bloodstream infection (n=6). Overall (pre- and post-operative) median ICU LOS was 4 days (IQR 2-10), while median post-operative ICU LOS was 3 days (IQR 2-8). Median hospital LOS was 11 days (IQR 8-20). Overall mortality was 6.7% (n=8).

Conclusions

In 119 consecutive children (including neonates and small infants) undergoing surgery for CHD between April 2020 and January 2021 the most frequent complication post-operatively was AKI development (15.9%). Mortality was 6.7%.

Background and Aims

– Background

Neonatologist performed echocardiography (NPE) has increasingly been used to assess the hemodynamic status in neonates.The joint outreach neonatal cardiology service where a paediatric cardiologist works closely with a neonatologist with an interest in neonatal cardiology would ensure that the more needy patients can be easily cared locally .

Hence in collaboration with Paediatric Cardiology team from Evelina children hospital new weekly joint cardiology service in NICU, King's College Hospital was established in Aug 2018.

– Aims

To evaluate frequency of use of echocardiography, patient characteristics, indications, and impact on patient management of Joint cardiology in a neonatal intensive care unit (NICU) in King’s College Hospital over a 1 year period.

Methods

A retrospective study conducted in NICU patients during 1 year. Aug 2018-Sept 2019

Results

– Results

Since the start of service in Aug 2018 to Sept 2019:

47 weekly joint cardiology ward rounds have occurred.

308 echocardiography were performed. 223(72%) echocardiography was performed by Neonatologist with cardiology interest and 85 (28%) echocardiography was performed by visiting cardiologist.

Ruling out congenital heart disease, pulmonary hypertension assessment and PDA assessment were common indications.

Most of the patients managed locally

Conclusions

– Conclusion

Neonatologist performed echocardiography is frequently used in the NICU, and in many cases it guides treatment. Collaborative working with cardiologist ensures maintaining the competences of NPE, quality including patient experience and outcomes.