Point of care serum lactate levels as a prognostic marker of outcome in complex pediatric cardiac surgery patients: Can we utilize it?

Background:

Post-operative course after complex pediatric cardiac surgery is unpredictable. Although, change in arterial lactate levels has been used as a surrogate marker for many years, scientific evidence correlating the early perioperative lactate levels with outcome is still lacking.

Objective:

To evaluate the trends in lactate levels from intraoperative period to an extended post-operative period in pediatric intensive care unit (PICU) and to assess its usefulness as a prognostic marker.

Design:

Prospective observational study.

Setting:

Tertiary pediatric cardiac surgical unit.

Patients:

Thirty-five non-consecutive children aged 1-140 months who underwent surgery for congenital heart diseases (CHD) on cardiopulmonary bypass (CPB).

Intervention:

None.

Materials and Methods:

Arterial blood lactate levels were obtained at the following time points: After induction of anesthesia, 15 and 45 min after institution of CPB, at the start of rewarming, after sternotomy closure, then at 1, 6, 24, and 48 h in PICU. Other hemodynamic and clinical variables, CPB variables, blood gas values, and laboratory variables were also recorded.

Results:

Four patients died out of 35 patients (11.4%). Non-survivors showed significant persistent elevation in lactates (>4.0 mmol/l). Peak lactates correlate significantly with longer aortic cross clamp time, CPB duration, ventilation hours and PICU stay.

Conclusion:

Early point of care lactate can be a useful prognostic marker in post-cardiac surgery patients in adjunct with other parameters measured in PICU. This reiterates the importance of measuring lactates and timely recognition of at-risk patients, which on early intervention can help in reducing post-operative morbidity and mortality.     

Plasma neutrophil gelatinase-associated lipocalin as an early biomarker for prediction of acute kidney injury after cardio-pulmonary bypass in pediatric cardiac surgery

Introduction

Cardiopulmonary bypass (CPB) surgery is considered one of the most frequent surgical procedures in which acute kidney injury (AKI) represents a frequent and serious complication. The aim of the present study was to evaluate the efficiency of neutrophil gelatinase-associated lipocalin (NGAL) as an early AKI biomarker after CPB in pediatric cardiac surgery.

Material and methods

The study included forty children aged 2 to 78 months undergoing CPB. They were divided into group I: patients who suffered AKI grades II and III; and group II: patients who did not develop AKI or at risk. Peripheral venous blood was withdrawn pre- and post-operatively for serial measurements of NGAL and creatinine. Statistical analysis was performed using Statistical Package for Social Sciences version 14.

Results

Mean plasma NGAL levels showed highly significant elevations in group I patients at 2, 12, and 24 h after surgery (p < 0.0001) compared to group II. Significant correlations were found between NGAL and creatinine at different time intervals. Highly significant correlations (p < 0.0001) were found between plasma NGAL and AKI at 2, 12 and 24 h after surgery. A cut-off level of 100 ng/ml at 2 h, and 125 ng/ml at 12 h post-operatively both recorded the highest accuracy, being 95% accurate, with sensitivity of 100% and 89.5% respectively, and specificity of 90.5% and 100% respectively.

Conclusions

This study showed that plasma NGAL could be used as an early biomarker for detection of AKI following CPB. We recommend further studies on a wider scale to validate the current study results.     

Incidence and management of diaphragmatic palsy in patients after cardiac surgery

Background:

Diaphragm is the most important part of the respiratory system. Diaphragmatic palsy following cardiac surgery is not uncommon and can cause deterioration of pulmonary functions and attendant pulmonary complications.

Objectives:

Aim of this study was to observe the incidence of diaphragmatic palsy after off pump coronary artery bypass grafting (OPCAB) as compared to conventional CABG and to assess the efficacy of chest physiotherapy on diaphragmatic palsy in post cardiac surgical patients.

Design and Setting:

An observational prospective interventional study done at a tertiary care cardiac centre.

Patients:

2280 consecutive adult patients who underwent cardiac surgery from February 2005 to august 2005.

Results:

30 patients out of 2280 (1.31%) developed diaphragmatic palsy. Patients were divided based on the presence or absence of symptoms viz. breathlessness at rest or exertion or with the change of posture along with hypoxemia and / or hypercapnia. Group I included 14 patients who were symptomatic (CABG n=13, post valve surgery n=1), While Group II included 16 asymptomatic patients (CABG n=12, post valve surgery n=4), 9 patients (64%) from Group I (n=14) and 4 patients (25%) from group II showed complete recovery from diaphragmatic palsy as demonstrated ultrasonographically.

Conclusion:

The incidence of diaphragmatic palsy was remarkably less in our adult cardiac surgical patients because most of the cardiac surgeries were performed off pump and intensive chest physiotherapy beginning shortly after extubation helped in complete or near complete recovery of diaphragmatic palsy. Chest Physiotherapy led to marked improvement in functional outcome following post cardiac surgery diaphragmatic palsy.We also conclude that ultrasonography is a simple valuable bed-side tool for rapid diagnosis of diaphragmatic palsy     

The assessment of neural injury following open heart surgery by physiological tremor analysis

Introduction

The appearance of post-operative cognitive dysfunction as a result of open heart surgery has been proven by several studies. Focal and/or sporadic neuron damage emerging in the central nervous system may not only appear as cognitive dysfunction, but might strongly influence features of physiological tremor.

Material and methods

We investigated 110 patients (age: 34-73 years; 76 male, 34 female; 51 coronary artery bypass grafting (CABG), 25 valve replacement, 25 combined open heart surgery, 9 off-pump CABG) before surgery and after open-heart surgery on the 3^rd to 5^th post-operative day. The assessment of the physiological tremor analysis was performed with our newly developed equipment based on the Analog Devices ADXL 320 JPC integrated accelerometer chip. Recordings were stored on a PC and spectral analysis was performed by fast Fourier transformation (FFT). We compared power integrals in the 1-4 Hz, 4-8 Hz and 8-12 Hz frequency ranges and these were statistically assessed by the Wilcoxon rank correlation test.

Results

We found significant changes in the power spectrum of physiological tremor. The spectrum in the 8-12 Hz range (neuronal oscillation) decreased and a shift was recognised to the lower spectrum (p < 0.01). The magnitude of the shift was not significantly higher for females than for males (p < 0.157). We found no significant difference between the shift and the cross-clamp or perfusion time (p < 0.6450).

Conclusions

The assessment of physiological tremor by means of our novel, feasible method may provide a deeper insight into the mechanism of central nervous system damage associated with open heart surgery.     

Comparison of post-operative ICU sedation between dexmedetomidine and propofol in Indian population

Context:

Critically ill patients requiring mechanical ventilation frequently need sedatives and analgesics to facilitate their care. Dexmedetomidine, a short-acting alpha-2-agonist, possesses anxiolytic, anesthetic, hypnotic, and analgesic properties.

Aims:

The objective of this study was to evaluate the efficacy and safety of dexmedetomidine in comparison to propofol in the management of sedation for post-operative intensive care unit (ICU) patients, as a sedative agent.

Settings and Design:

Teaching hospital, A phase III, prospective, open, randomized and comparative.

Materials and Methods:

Thirty patients who were ambulatory and who required the post-operative mechanical ventilation or post-operative sedation were enrolled, in which 15 patients received Dexmedetomidine and remaining 15 patients received propofol. All these patients were treated for the period of 8 to 24 h.

Statistical Analysis Used:

Data were analyzed using Student''s t-test and Chi-square test. The value of P < 0.05 was considered as statistically significant.

Results:

Demographic data were comparable. Pulse rate, respiratory rate and blood pressure were comparable. Depth of sedation and extubation time were similar. To maintain analgesia throughout the study period, patients receiving propofol infusions required significantly more analgesics than patients receiving Dexmedetomidine.

Conclusions:

Dexmedetomidine appears to be a safe and acceptable ICU sedative agent when both the clinician''s and patient''s perspectives are considered.     

Clinical Implications and Risk Factors of Acute Pancreatitis after Cardiac Valve Surgery

Purpose

Acute pancreatitis is one of the potentially lethal complications that occurs after cardiac surgery. We tried to identify risk factors for and the prognosis of acute pancreatitis after cardiac valve surgery with cardiopulmonary bypass.

Materials and Methods

We retrospectively analyzed a database of consecutive patients who underwent cardiac valve surgery with cardiopulmonary bypass between January 2005 and April 2010 at our institution. Patients were classified as having acute pancreatitis based on serum lipase concentration and clinical symptoms (lipase ≥180 U/L or ≥60 U/L with relevant symptoms).

Results

Of the 986 patients who underwent cardiac valve surgery with cardiopulmonary bypass, 58 (5.9%) patients developed post-operative pancreatitis. Post-operative hospital stay was significantly longer (29.7±45.6 days vs. 12.4±10.7 days, p=0.005) and in-hospital mortality rate was higher (15.5% vs. 2.0%, p<0.001) in patients with post-operative pancreatitis than those without. Hypertension, chronic kidney disease, and peri-operative use of norepinephrine were identified as independent risk factors for developing pancreatitis after cardiac valve surgery.

Conclusion

We found that acute pancreatitis after cardiac valve surgery requires longer hospitalization and increases the in-hospital mortality rate. Clinicians should be aware that patients could develop pancreatitis after cardiac valve surgery, especially in patients with hypertension and chronic kidney disease treated with norepinephrine.     

Early clinical prediction of neurological outcome following out of hospital cardiac arrest managed with therapeutic hypothermia

Background:

Therapeutic hypothermia (TH) may improve neurological outcome in comatose patients following out of hospital cardiac arrest (OHCA). The reliability of clinical prediction of neurological outcome following TH remains unclear. In particular, there is very limited data on survival and predictors of neurological outcome following TH for OHCA from resource-constrained settings in general and South Asia in specific.

Objective:

The objective was to identify factors predicting unfavorable neurological outcome at hospital discharge in comatose survivors of OHCA treated with hypothermia.

Design:

Retrospective chart review.

Setting:

Urban 200-bed hospital in Chennai, India.

Methods:

Predictors of unfavorable neurological outcome (cerebral performance category score [3–5]) at hospital discharge were evaluated among patients admitted between January 2006 and December 2012 following OHCA treated with TH. Hypothermia was induced with cold intravenous saline bolus, ice packs and cold-water spray with bedside fan. Predictors of unfavorable neurological outcome were examined through multivariate exact logistic regression analysis.

Results:

A total of 121 patients were included with 106/121 (87%) experiencing the unfavorable neurological outcome. Independent predictors of unfavorable neurological outcome included: Status myoclonus <24 h (odds ratio [OR] 21.79, 95% confidence interval [CI] 2.89-Infinite), absent brainstem reflexes (OR 50.09, 6.55-Infinite), and motor response worse than flexion on day 3 (OR 99.41, 12.21-Infinite). All 3 variables had 100% specificity and positive predictive value.

Conclusion:

Status myoclonus within 24 h, absence of brainstem reflexes and motor response worse than flexion on day 3 reliably predict unfavorable neurological outcome in comatose patients with OHCA treated with TH.     

Dysregulation of Heart Rhythm During Sleep in Leptin-Deficient Obese Mice

Study Objectives:

Sleep deeply affects cardiac autonomic control, the impairment of which is associated with cardiovascular mortality. Obesity entails increased cardiovascular risk and derangements in sleep and cardiac autonomic control. We investigated whether cardiac autonomic control is impaired during sleep in ob/ob mice with morbid obesity caused by congenital leptin deficiency.

Design:

Indexes of cardiac autonomic control based on spontaneous cardiovascular fluctuations were compared between ob/ob and lean wild-type (+/+) mice during wakefulness, non-rapid eye movement sleep (NREMS), and rapid eye movement sleep (REMS).

Setting:

N/A

Patients or Participants:

7 ob/ob and 11 +/+ male mice.

Interventions:

Instrumentation with electrodes for sleep recordings and a telemetric transducer for measuring blood pressure and heart period.

Measurements and Results:

In ob/ob mice, the variability of heart period and cardiac baroreflex sensitivity (sequence technique) were significantly lower than in +/+ mice during each wake-sleep state. The vagal modulation of heart period was significantly weaker in ob/ob than in +/+ mice during NREMS and REMS. In ob/ob mice, the cross-correlation function between heart period and blood pressure suggested that the baroreflex contribution to cardiac control was lower than in +/+ mice during wakefulness and NREMS, whereas the contribution of central autonomic commands was lower than in +/+ mice during NREMS and REMS.

Conclusions:

These data indicate a dysregulation of cardiac autonomic control during sleep in ob/ob mice. Ob/ob mice may represent a useful tool to understand the molecular pathways that lead to cardiac autonomic dysregulation during sleep in obesity.

Citation:

Silvani A; Bastianini S; Berteotti C; Franzini C; Lenzi P; Lo Martire V; Zoccoli G. Dysregulation of heart rhythm during sleep in leptin-deficient obese mice. SLEEP 2010;33(3):355-361.     

Aerobic exercise improves the inflammatory profile correlated with cardiac remodeling and function in chronic heart failure rats

OBJECTIVE:

The aim of the present study was to evaluate the effect of 8 weeks of aerobic exercise training on cardiac functioning and remodeling and on the plasma levels of inflammatory cytokines in chronic heart failure rats.

METHODS:

Wistar rats were subjected to myocardial infarction or sham surgery and assigned to 4 groups: chronic heart failure trained (n = 7), chronic heart failure sedentary (n = 6), sham trained (n = 8) and sham sedentary (n = 8). Four weeks after the surgical procedures, the rats were subjected to aerobic training in the form of treadmill running (50 min/day, 5 times per week, 16 m/min). At the end of 8 weeks, the rats were placed under anesthesia, the hemodynamic variables were recorded and blood samples were collected. Cardiac hypertrophy was evaluated using the left ventricular weight/body weight ratio, and the collagen volume fraction was assessed using histology.

RESULTS:

The chronic heart failure trained group showed a reduction in left ventricular end-diastolic pressure, a lower left ventricular weight/body weight ratio and a lower collagen volume fraction compared with the chronic heart failure sedentary group. In addition, exercise training reduced the plasma levels of TNF-α and IL-6 and increased the plasma level of IL-10.

CONCLUSION:

An 8-week aerobic exercise training program improved the inflammatory profile and cardiac function and attenuated cardiac remodeling in chronic heart failure rats.     

Baseline Demographic Profile and General Health Influencing the Post-Radiotherapy Health Related Quality-of-Life in Women with Gynaecological Malignancy Treated with Pelvic Irradiation

Background:

Cancer specific survival and quality-of-life (QOL) assessment are important in evaluating cancer treatment outcomes. Baseline demographic profiles have significant effects on follow-up health related QOL (HRQOL) and affect the outcome of treatments.

Materials and Methods:

Post-operative gynaecological cancer patients required adjuvant pelvic radiation enrolled longitudinal assessment study. Patients had completed the short form-36 (SF-36) questionnaire before the adjuvant radiotherapy and functional assessments of cancer therapy-general module at 6^th month''s follow-up period to assess the HRQOL. Baseline variables were race, age, body mass index (BMI), education, marital status, type of surgery, physical composite scores (PCS) and mental composite scores (MCS) summary scores of the SF-36. Univariate and multivariate regression analysis used to determine the influence of these variables on post-radiotherapy HRQOL domains.

Results:

Baseline PCS, MCS, age, education and marital status had positively correlation with post-radiotherapy HRQOL while higher BMI had a negative impact in univariate analysis. In multivariate regression analysis, education and MCS had a positive correlation while higher BMI had a negative correlation with HRQOL domains.

Conclusion:

Enhance our ability to detect demographic variables and modify those factors and develops new treatment aimed at improving all aspect of gynaecological cancer including good QOL.     

Expression of angiogenesis-related genes in right atrial appendages from patients with advanced myocardial ischemia – preliminary results

Introduction

The most frequent cause of myocardial ischemia is atherosclerotic lesions which narrow coronary vessels leading to impaired blood flow or their total occlusion.

Material and methods

Using HG-U133A oligonucleotide microarrays (Affymetrix) we studied the expression levels of angiogenesis-related genes in patients with different types of heart failure. We analyzed the RNA from right atrial appendages from patients: 1) with advanced coronary disease and myocardial infarction history, 2) with advanced stable coronary disease and no infarction history, and 3) after surgery due to mitral stenosis, but with no coronary vessel lesions.

Results

Analysis of the data from oligonucleotide microarrays allowed identification of 2 genes (ENG and NPPB) differentiating the examination grups.

Conclusions

Analysis of the expression profile of genes involved in angiogenesis, carried out using data obtained from examined individuals’ samples, suggests that necrosis accompanying myocardial infarction is a significant factor leading to elevated expression levels of genes involved in neoangiogenesis.     

23-year experience on diagnosis and surgical treatment of benign and malignant cardiac tumors

Introduction

Although myxoma is the most frequent cardiac tumor, other conditions should be taken into consideration in the differential diagnosis. Transthoracic echocardiography (TTE), followed by transesophageal echocardiography (TEE) remain the principal methods for cardiac tumor screening and visualizing. The aim of the study was to compare the diagnostics, surgical treatment and prognosis of malignant and benign cardiac tumors.

Material and methods

From 1986 to 2009 there were 121 patients with cardiac tumors operated on in the Cardiac Surgery Clinic of the Medical University in Lodz. Patients were referred to surgery mainly on the basis of the TTE and TEE image. In 4 cases valvular prosthesis implantation or valve repair were carried out. Patients remained under long-term observation in the Cardiac Surgery Outpatient Clinic.

Results

Myxoma was diagnosed in 114 cases. Malignancies were discovered in 7 cases. The left atrium was the most frequent localization. The echocardiographic image differed significantly in benign and malignant tumors. The postoperative period was complicated by embolic events or myocardial infarctions. Only malignant tumors were associated with mortality due to cardiovascular events. The survival for malignant tumors was significantly shorter.

Conclusions

Short and long-term results of operative treatment are very good for benign tumors in contrast to cardiac malignancies. The TTE and TEE image can be very significant in the final diagnosis.     

Association between electrocardiographic findings and cardiac dysfunction in adult isolated traumatic brain injury

Introduction:

Abnormal electrocardiographic (ECG) findings can be seen in traumatic brain injury (TBI) patients. ECG may be an inexpensive tool to identify patients at high risk for developing cardiac dysfunction after TBI. The aim of this study was to examine abnormal ECG findings after isolated TBI and their association with true cardiac dysfunction, based on echocardiogram.

Methods:

Data from adult patients with isolated TBI between 2003 and 2010 was retrospectively examined. Inclusion criteria included the presence of a 12-lead ECG within 24 h of admission and a formal echocardiographic examination within 72 h of admission after TBI. Patients with preexisting cardiac disease were excluded. Baseline clinical characteristics, 12-lead ECG, and echocardiogram report were abstracted. Logistic regression was used to identify the relationship of specific ECG abnormalities with cardiac dysfunction.

Results:

We examined data from 59 patients with isolated TBI who underwent 12-lead ECG and echocardiographic evaluation. In this cohort, 13 (22%) patients had tachycardia (heart rate >100 bpm), 25 (42.4%) patients had a prolonged QTc, and 6 (10.2%) patients had morphologic end-repolarization abnormalities (MERA), with each having an association with abnormal echocardiographic findings: Odds ratios (and 95% confidence intervals) were 4.14 (1.02-17.05), 9.0 (1.74-46.65), and 5.63 (1.96-32.94), respectively. Ischemic-like ECG changes were not associated with echocardiographic abnormalities.

Conclusions:

Repolarization abnormalities (prolonged QTc and MERA), but not ischemic-like ECG changes, are associated with cardiac dysfunction after isolated TBI. 12-lead ECG may be an inexpensive screening tool to evaluate isolated TBI patients for cardiac dysfunction prior to more expensive or invasive studies.     

Evaluation of T-wave alternans in high-resolution ECG maps recorded during the stress test in patients after myocardial infarction

Introduction

Recent studies point to analysis of T-wave alternans as a promising indicator of an increased risk of life-threatening ventricular arrhythmias. In this study the occurrence of T-wave alternans in the high-resolution ECGs recorded during the exercise stress test and scintigraphic tests (SPECT) in patients with ischemic heart disease was examined.

Material and methods

The study group consisted of 33 patients after myocardial infarction. In the group of patients after myocardial infarction and with low left ventricular ejection fraction correlations of 70% between the test results of T-wave alternans and SPECT and 60% between the test results of T-wave alternans and stress test were found.

Results

In the group of patients after myocardial infarction but with high left ventricular ejection fraction correlations were respectively 39% and 48%. The analysis of the electrocardiographic maps showed a strong dependence of this correlation on the T-wave alternans amplitude and location of the ECG measuring electrode on the chest. The results might suggest that in patients after myocardial infarction and at increased risk for sudden cardiac death T-wave alternans may also provide information about cardiac electrical instability associated with ischemia.

Conclusions

It can also be assumed that the position of the electrode where the highest level of the T-wave alternans was detected can indicate the location of the ischemic region of the heart.     

Predictors of septic shock following anastomotic leak after major gastrointestinal surgery: An audit from a tertiary care institute

Background:

Anastomotic leak is a serious complication after major gastrointestinal surgery and majority of deaths occur due to septic shock. Therefore, the early identification of risk factors of septic shock may help reduce the adverse outcomes.

Objective:

The aim of this audit was to determine the predictors of septic shock in patients with anastomotic leak after major gastrointestinal surgery.

Design:

Retrospective, audit.

Materials and Methods:

The patients admitted in the gastrosurgical intensive care unit ICU) of our institute between September 2009 and April 2012 with anastomotic leakage after surgery were identified. The ICU charts were retrieved from the database to identify the patients progressing to septic shock. A comparison of risk factors was made between the patients who developed septic shock (septic shock group) against the patients who did not (non-septic shock group).

Results:

The study sample comprised of 103 patients with anastomotic leak, of which 72 patients developed septic shock. The septic shock group had a higher APACHE II score, lower MAP, and higher HR at the time of ICU admission. They received greater transfusion of packed red blood cells during their ICU stay. Septic shock was more common after pancreaticojejunostomy and hepaticojejunostomy leaks.

Conclusion:

Presence of malignancy, chronic obstructive pulmonary disease (COPD), packed red blood cell transfusion, bacteremia, and hepaticojejunostomy or pancreaticojejunostomy leaks were independent predictors of mortality and length of ICU stay. To the best of our knowledge there are no available studies in the literature on the predictors of risk factors of septic shock in patients with anastomotic leakage.     

Performance after rotator cuff tear and operative treatment: a case-control study of major league baseball pitchers

Context:

Little is known about pitching performance or lack of it among Major League Baseball (MLB) pitchers who undergo operative treatment of rotator cuff tears.

Objective:

To assess pitching performance outcomes in MLB players who needed operative treatment of rotator cuff tears and to compare performance in these athletes with that in a control group of MLB players.

Design:

Case-control study.

Setting:

Publicly available player profiles, press releases, and team injury reports.

Patients or Other Participants:

Thirty-three MLB pitchers with documented surgery to treat rotator cuff tears and 117 control pitchers who did not have documented rotator cuff tears were identified.

Main Outcome Measure(s):

Major League Baseball pitching attrition and performance variables.

Results:

Players who underwent rotator cuff surgery were no more likely not to play than control players. Performance variables of players who underwent surgery improved after surgery but never returned to baseline preoperative status. Players who needed rotator cuff surgery typically were more experienced and had better earned run averages than control players.

Conclusions:

Pitchers who had symptomatic rotator cuff tears that necessitated operative treatment tended to decline gradually in performance leading up to their operations and to improve gradually over the next 3 seasons. In contrast to what we expected, they did not have a greater attrition rate than their control counterparts; however, their performances did not return to preoperative levels over the course of the study.     

Pattern of in-hospital pediatric mortality over a 3-year period at University teaching hospitals in Iran

Introduction:

Causes of death are different and very important for policy makers in different regions. This study was designed to analyze the data for our in-patient children mortality.

Materials and Methods:

In this cross-sectional study from March 2011 to March 2013, all patients from 2 months to 18 years who died in pediatric intensive care unit, emergency room or medical pediatric wards in the teaching hospitals were studied.

Results:

From a total of 18,915 admissions during a 2-year-period, 256 deaths occurred with a mean age of 4.3 ± 5 years and mortality 1.35%. An underlying disease was present in 70.7% of the patients and in 88.5% of them the leading causes of death were related to the underlying diseases. The most common underlying diseases were congenital heart disease and cardiomyopathy in 50 (27.6%). The four main causes of deaths were sepsis (14.8%), pneumonia (14.5%), congestive heart failure (9.8%), and hepatic encephalopathy (9.8%).

Conclusion:

We may conclude that after sepsis and pneumonia, congestive heart failure, and hepatic encephalopathy are the leading causes of death. Most patients who died had underlying diseases including malignancies, heart and liver diseases as the most common causes.     

Intra- or extracardiac Fontan operation? A simple strategy when to do what

Introduction

The complete Fontan circulation is the definite palliation for many complex congenital cardiac lesions. After bi-directional Glenn anastomosis (BDG), two well-established techniques – intracardiac tunneling and extracardiac prosthesis – are available for completion, although the choice of technique is still a matter of debate.

Material and methods

We retrospectively reviewed the surgical and clinical records of patients with single ventricle physiology, who underwent intracardiac (group I) or extracardiac (group II) Fontan palliation after BDG.

Results

Complete data were available in 72 patients. Thirty-eight patients received intracardiac (median weight: 12.6 kg) and 34 patients extracardiac repair (median weight: 15.6 kg). Patients with intracardiac tunneling had longer cardiopulmonary bypass (CBP) time (170 min vs. 104 min; p < 0.001), longer ventilatory (39 h vs. 21 h; p = 0.009) and longer inotropic support (48 h vs. 10 h; p < 0.001). Ventilatory and inotropic support were dependent on CPB (r = 0.69 and r = 0.637) and on aortic cross-clamping (r = 0.785 and r = 0.705 only group I), but not dependent on age, weight or pulmonary artery pressure (PAP).

Conclusions

Both techniques are feasible without perioperative mortality. Normally developed children with good hemodynamics after BDG received an elective extracardiac procedure without fenestration later. Patients with developmental retardation, severe progressive cyanosis, myocardial dysfunction, or moderate to severe atrio-ventricular valve insufficiency are scheduled for an earlier intracardiac baffle repair with routine fenestration, as they are at higher risk. Prolonged CPB and aortic cross-clamping times adversely impact the early postoperative course. Further strategies must be developed to avoid these effects, particularly in the patient group at higher imminent risk.     

Hyponatremia in critically ill patients

Context:

Hyponatremia is a common electrolyte disturbance in critically ill hence understanding its implications is important.

Aims:

This study was carried out to ascertain frequency, predisposing conditions and outcome in critically ill patients with hyponatremia on intensive care unit (ICU) admission.

Settings and Design:

This was an observational, prospective study of a series of ICU patients during a 12-month period.

Materials and Methods:

The patients were divided into two groups: Hyponatremic (serum sodium < 135 mmol/L) and Eunatremic groups (135-145 mmol/L). Clinical examination included volume status and drug history, biochemistries, clinical diagnosis and cause of hyponatremia.

Statistical Analysis Used:

Fisher''s exact test, unpaired t-tests Wilcoxon ranksum tests, profile-likelihood method, log-rank test and Kaplan—Meier curves were used. P < 0.05 were considered to be statistically significant.

Results:

In the hyponatremic group, the frequency of hyponatremia on ICU admission was 34.3%, most were euvolumic, 58.96%. Females comprised of 36.5%. The mean age was 60.4 ± 17.2. The Syndrome of inappropriate Antidiuretic Hormone (SIADH) criteria was met in ninety-one patients (36.25%), peumonia being the leading cause of SIADH. Patients with severe sepsis, elective surgery patients, renal failure and heart failure, cirrhosis of liver and subarachnoid hemorrhage were other more likely etiologic causes (P < 0.05). The hyponatremic group spent a longer time in the ICU (P = 0.02), had longer mechanical ventilator days (P < 0.05) and had an increased mortality rate (P = 0.01).

Conclusions:

Hyponatremia present on admission to the ICU is independent risk factors for poor prognosis.     

Bedside echocardiography is useful in assessing children with fluid and inotrope resistant septic shock

Objective:

To report changes in the cardiovascular management of fluid and inotropic resistant septic shock in children based on echocardiography.

Design:

Retrospective case series.

Setting:

Tertiary care Pediatric Intensive Care Unit (PICU), Chennai.

Patients:

Twenty-two patients with unresolved septic shock after 60 ml/kg fluid plus inotropic agents in the first hour.

Interventions:

Bedside echocardiography (echo) within 6 h of admission to the PICU.

Results:

Over a 28-month period, of 37 patients with septic shock, 22 children remained in shock despite 60 ml/kg fluid and dopamine and/or dobutamine infusions as per guidelines. On clinical exam, 12 patients had warm shock and ten had cold shock, however, six exhibited an unusual pattern of cold shock with wide pulse pressures on invasive arterial monitoring. The most common echocardiographic finding was uncorrected hypovolemia in 12/22 patient while ten patients had impaired left ± right ventricular function. Echocardiography permitted an appreciation of the underlying disordered pathophysiology and a rationale for adjustment of treatment. Shock resolved in 17 (77%) and 16 patients (73%) survived to discharge.

Conclusions:

Bedside echo provided crucial information that was not apparent on clinical assessment and affords a simple noninvasive tool to determine the cause of low cardiac output in patients who remain in shock despite 60 ml/kg fluid and inotropic support. Most patients in our series had vasodilatory shock with wide pulse pressures and most common finding on echo was uncorrected hypovolemia. The echo findings allowed adjustment of therapy which was not possible based on clinical examination alone.