Normothermia for Pediatric and Congenital Heart Surgery: An Expanded Horizon

Abstract

Cardiopulmonary bypass (CPB) in pediatric cardiac surgery is generally performed with hypothermia, flow reduction and hemodilution. From October 2013 to December 2014, 55 patients, median age 6 years (range 2 months to 52 years), median weight 18.5 kg (range 3.2–57 kg), underwent surgery with normothermic high flow CPB in a new unit. There were no early or late deaths. Fifty patients (90.9%) were extubated within 3 h, 3 (5.5%) within 24 h, and 2 (3.6%) within 48 h. Twenty-four patients (43.6%) did not require inotropic support, 31 (56.4%) received dopamine or dobutamine: 21 ≤5 mcg/kg/min, 8 5–10 mcg/kg/min, and 2 >10 mcg/kg/min. Two patients (6.5%) required noradrenaline 0.05–0.1 mcg/kg/min. On arrival to ICU and after 3 and 6 h and 8:00 a.m. the next morning, mean lactate levels were 1.9 ± 09, 2.0 ± 1.2, 1.6 ± 0.8, and 1.4 ± 0.7 mmol/L (0.6–5.2 mmol/L), respectively. From arrival to ICU to 8:00 a.m. the next morning mean urine output was 3.8 ± 1.5 mL/kg/h (0.7–7.6 mL/kg/h), and mean chest drainage was 0.6 ± 0.5 mL/kg/h (0.1–2.3 mL/kg/h). Mean ICU and hospital stay were 2.7 ± 1.4 days (2–8 days) and 7.2 ± 2.2 days (4–15 days), respectively. In conclusion, normothermic high flow CPB allows pediatric and congenital heart surgery with favorable outcomes even in a new unit. The immediate post-operative period is characterized by low requirement for inotropic and respiratory support, low lactate production, adequate urine output, minimal drainage from the chest drains, short ICU, and hospital stay.

Comparison of Early Outcomes for Normothermic and Hypothermic Cardiopulmonary Bypass in Children Undergoing Congenital Heart Surgery

“…Unfortunately H-CPB presents side effects, affecting all tissues and organs, with negative influence on clinical outcomes ( 1 , 3 – 6 ). To minimize the negative effects of hypothermia, normothermic CPB has been progressively used for repair of congenital heart defects ( 4 – 6 ).…”

Medical missions for the provision of paediatric cardiac surgery in low- and middle-income countries

“…57 Normothermic strategies during or post-bypass and use of warm air blowers assist in early extubation. 58,59 Fast-tracking reduces exposure to morbidity and mortality from failures of equipment, power, or gas, or ICU nursing presence or experience. Additional benefits include reductions in ICU sedation and inotrope requirements, ventilator-associated pneumonia, and ICU and hospital stay.…”

Rationale for Implementation of Warm Cardiac Surgery in Pediatrics

“…The results obtained with warm surgery in our unit proved reproducible. The benefits of warm perfusion on immediate outcomes were confirmed through low requirement for inotropic and short time to extubation, low lactate production, adequate urine output, minimal drainage from the chest drains, short ICU and hospital stay ( 89 ). When compared to hypothermic perfusion, warm perfusion was associated with reduced oxidative stress ( 90 ).…”

“…The absence of benefits of low temperature over warm perfusion on brain protection became ever more evident. Of note, several European units switched from cold to warm surgery, and none decided to shift back to hypothermia ( 89 – 94 ).…”