Objectives The American Clinical Neurophysiology Society recommends continuous electroencephalographic monitoring after neonatal cardiac surgery because seizures are common, often subclinical, and associated with worse neurocognitive outcomes. We performed a quality improvement project to monitor for postoperative seizures in neonates with congenital heart disease after surgery with cardiopulmonary bypass. Methods We implemented routine continuous electroencephalographic monitoring and reviewed the results for an 18-month period. Clinical data were collected by chart review, and continuous electroencephalographic tracings were interpreted using standardized American Clinical Neurophysiology Society terminology. Electrographic seizures were classified as electroencephalogram-only or electroclinical seizures. Multiple logistic regression was used to assess associations between seizures and potential clinical and electroencephalogram predictors. Results A total of 161 of 172 eligible neonates (94%) underwent continuous electroencephalographic monitoring. Electrographic seizures occurred in 13 neonates (8%) beginning at a median of 20 hours after return to the intensive care unit after surgery. Neonates with all types of congenital heart disease had seizures. Seizures were electroencephalogram only in 11 neonates (85%). Status epilepticus occurred in 8 neonates (62%). In separate multivariate models, delayed sternal closure or longer deep hypothermic circulatory arrest duration was associated with an increased risk for seizures. Mortality was higher among neonates with than without seizures (38% vs 3%, P<.001). Conclusions Continuous electroencephalographic monitoring identified seizures in 8%of neonates after cardiac surgery with cardiopulmonary bypass. The majority of seizures had no clinical correlate and would not have been otherwise identified. Seizure occurrence is a marker of greater illness severity and increased mortality. Further study is needed to determinewhether seizure identification and management lead to improved outcomes.

. INVITED COMMENTARYI read with interest the article by Chen and colleagues [1]. A 10% incidence of perioperative stroke is a possible partial explanation for less than ideal neurodevelopmental outcomes in congenital heart disease (CHD) [2,3]. Additional explanations are genetic causes [4], fetal development with CHD, and injury that is not measured by imaging. If we are to improve neurologic outcomes, there are four areas in which practice improvement needs to become uniform or further explored: (1) prenatal diagnosis and maternal care, (2) postnatal preoperative care, (3) operative interventional strategies, and (4) postoperative care. Specifics of these are briefly discussed. 1.Can fetal diagnosis and maternal care for all having CHD impact birth weight and thereby mitigate this as a risk? 2.Can fetal triage to a congenital cardiac liaised high-risk obstetrics and neonatal team preclude cardiorespiratory instability in more babies and thus lessen preoperative stroke? 3.Risk was shown to be modifiable in the operating room. A higher hematocrit (28% vs 26%) on cardiopulmonary bypass (CPB) was associated with a lower incidence of stroke. This corroborates previous findings that hematocrit on CPB is important [5]. Not all factors believed to be a risk in the operating room were actually a risk. Circulatory arrest, as performed and compared, did not impact neurodevelopment. Fruitful areas for further study will include hybrid stage I versus conventional stage I palliation for single ventricle and arch obstruction, further human studies on pCO2 management strategy for CPB, rate of CPB flow, and others. 4.Postoperative measurements, such as systemic oxygen delivery [6], length of stay in the intensive care unit, and other factors are also important and potentially modifiable.Survival with CHD has become an expectation. It is our duty to ensure that those unfortunate enough to have CHD not only survive, but live. Continued critical data analysis in the areas outlined, trials, and modification of practice will allow us to help our patients live-in the fullest sense. AbstractBackground-The prevalence of perioperative stroke in infants undergoing operations for congenital heart disease has not been well described. The objectives of this study were to determine the prevalence of stroke as assessed by postoperative brain magnetic resonance imaging (MRI), characterize the neuroanatomic features of focal ischemic injury, and identify risk factors for its development.

Interleukin-6 (IL-6) regulates hepatic acute phase responses by activating the transcription factor signal transducer and activator of transcription (STAT)-3. IL-6 also may modulate septic pathophysiology. We hypothesize that 1) STAT-3 activation and transcription of α2-macroglobulin (A2M) correlate with recovery from sepsis and 2) STAT-3 activation and A2M transcription reflect intrahepatic and not serum IL-6. Nonlethal sepsis was induced in rats by single puncture cecal ligation and puncture (CLP) and lethal sepsis via double-puncture CLP. STAT-3 activation and A2M transcription were detected at 3–72 h and intrahepatic IL-6 at 24–72 h following single-puncture CLP. All were detected only at 3–16 h following double-puncture CLP and at lower levels than following single-puncture CLP. Loss of serum and intrahepatic IL-6 activity after double-puncture CLP correlated with mortality. Neither intrahepatic nor serum IL-6 levels correlated with intrahepatic IL-6 activity. STAT-3 activation following single-puncture CLP inversely correlated with altered transcription of gluconeogenic, ketogenic, and ureagenic genes. IL-6 may have both beneficial and detrimental effects in sepsis. Fulminant sepsis may decrease the ability of hepatocytes to respond to IL-6.

No abstract