Nitric oxide administration during paediatric cardiopulmonary bypass: a randomised controlled trial

James, Christopher; Millar, Johnny; Horton, Stephen; Brizard, Christian P.; Molesworth, Charlotte; Butt, Warwick

doi:10.1007/s00134-016-4420-6

Cited by 86 publications

(92 citation statements)

References 38 publications

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“…For example a patient receiving 0.5 μg/kg/min of milrinone and 5 μg/kg/ min of dopamine would have a VIS of at least 10, which could be classed as standard postoperative support in many units. This is supported by the data provided in James et al 's supplementary Tables 2 and 4 [11], demonstrating that only 18% (7/40) of patients with a VIS score of at least 10 had a raised lactate and low SvO 2 , suggesting inadequate systemic oxygen delivery.…”

supporting

confidence: 54%

“…In a recent article in Intensive Care Medicine, James et al extended these findings in a well-conducted single-centre randomised controlled trial in 198 children undergoing surgery with CPB [11]. The primary outcome measure was the incidence of LCOS, which the authors defined as one or more of the following: lactate greater than 4 mmol/l and ScvO 2 less than 60% (or SaO 2 − ScvO 2 difference greater than 35% in a single ventricle), a vasoactive inotrope score (VIS) greater than 10 or the need for ECMO.…”

mentioning

confidence: 91%

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Paediatric cardiopulmonary bypass surgery: the challenges of heterogeneity and identifying a meaningful endpoint for clinical trials

2016

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supporting

confidence: 54%

mentioning

confidence: 91%

Paediatric cardiopulmonary bypass surgery: the challenges of heterogeneity and identifying a meaningful endpoint for clinical trials

2016

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“…Administration of NO donors (such as L‐Arginine) has been proven protective against reperfusion injury experimental models. Two pediatric trials demonstrated a lower incidence of low cardiac output syndrome when NO was delivered at 20 ppm directly to the oxygenator, as well as lower troponin and BNP concentrations, a shorter duration of mechanical ventilation and ICU stay, less postoperative NO requirement, and less dialysis requirement for kidney injury . The effect on the incidence of postoperative low cardiac output was most marked in patients aged less than 6 weeks of age and following more complex surgeries, including hypothermic CPB: it is likely that through the inhibition of the enzymatic NO pathway, hypothermia further decreases the bioavailability of NO.…”

Section: Biocompatibilitymentioning

confidence: 99%

“…Due to antiapoptotic effects, NO could provide myocardial protection during reperfusion. Indeed, decreased postoperative troponin concentrations and a decreased incidence of low cardiac output have been reported after NO administration during CPB …”

Section: Myocardial Protectionmentioning

confidence: 99%

Recent achievements and future developments in neonatal cardiopulmonary bypass

Bojan

2019

Pediatric Anesthesia

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Summary A primary goal of improving neonatal cardiopulmonary bypass has been making the circuit smaller and reduce the blood contacting surfaces. As bypass circuit size has decreased, bloodless surgery has become possible even in neonates. Since transfusion guidelines are difficult to construct based on existing literature, these technical advances should be taken advantage of in conjunction with an individualized transfusion scheme, based on monitoring of oxygen availability to the tissues. For the majority of neonatal heart operations, several centers have shifted toward normothermic bypass even for complex neonatal surgeries, in order to avoid the adverse effects of hypothermia. Deep hypothermic circulatory arrest is no longer a necessity but an option, and selective antegrade cerebral perfusion has become common practice; however, technical uncertainties with regard to this technique have to be addressed, based on reliable neurologic monitoring. Maintenance of patient‐specific heparin concentrations during bypass is another key goal, since neonates have lower baseline antithrombin concentrations and, therefore, a higher risk for inadequate thrombin inhibition and postoperative bleeding. Due to the immaturity of their hemostatic system, the standard coagulation tests alone are inappropriate to guide hemostatic therapy in neonates. The use of indirect heparin concentration assays and global viscoelastic assays in the operating room is likely to represent the optimal strategy, and requires validation in neonates. Monitoring of global and regional indexes of oxygen availability and consumption on bypass have become possible; however, their use in neonates still has outstanding technical issues which should be addressed and hence needs further validation. Due to the immaturity of the neonatal myocardium, single‐shot cold cardioplegia solutions are thought to confer the best myocardial protection; their superiority when compared to more conventional modalities, however, remains to be demonstrated.

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“…How is one to determine which blood pressure targets are optimal in septic shock when it is not even clear how to best to measure? Finally, although not sepsis, James and colleagues studied use of nitric oxide (NO) during cardiopulmonary bypass-another systemic inflammatory insult-and found that patients randomized to NO had a lower incidence of cardiogenic shock and reduced length of stay, especially in neonates and complex heart disease [11]. Perhaps ameliorating reperfusion injury is as important as reperfusion itself.…”

Section: Sepsismentioning

confidence: 99%