Postoperative lactate concentrations predict the outcome of infants aged 6 weeks or less after intracardiac surgery: A cohort follow-up to 18 months

Cheung, Po-Yin; Chui, Natalie; Joffe, Ari R.; Rebeyka, Ivan M.; Robertson, Charlene M.T.

doi:10.1016/j.jtcvs.2005.04.029

Cited by 95 publications

(70 citation statements)

References 26 publications

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“…Increased preoperative lactate levels have been found to be associated with lower functional abilities after CCS, 44 with mental and/or motor delay in children undergoing arterial switch operations, 45 and as indicators of postoperative mortality and morbidity. [46][47][48] Preoperative plasma lactate levels and age at surgery are modifiable variables that could potentially lead to a reduction in CND the same way other advances have affected specific prevalence rates of CP. 29,33 Specific in utero and perioperative neuroprotective strategies to achieve these goals should be further investigated.…”

Section: Figurementioning

confidence: 99%

Chronic Neuromotor Disability After Complex Cardiac Surgery in Early Life

Ricci¹,

Andersen

Joffe

et al. 2015

Pediatrics

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BACKGROUND AND OBJECTIVES: Little is known about chronic neuromotor disability (CND) including cerebral palsy and motor impairments after acquired brain injury in children surviving early complex cardiac surgery (CCS). We sought to determine the frequency and presentation of CND in this population while exploring potentially modifiable acute care predictors.METHODS: This prospective follow-up study included 549 children after CCS requiring cardiopulmonary bypass at #6 weeks of age. Groups included those with only 1 CCS, mostly biventricular CHD, and those with .1 CCS, predominantly single ventricle defects. At 4.5 years of age, 420 (94.6%) children received multidisciplinary assessment. Frequency of CND is given as percentage of assessed survivors. Predictors of CND were analyzed using multiple logistic regression analysis.RESULTS: CND occurred in 6% (95% confidence interval [CI] 3.7%-8.2%) of 4.5-year survivors; for 1 CCS, 4.2% (CI 2.3%-6.1%) and .1, 9.8% (CI 7%-12.6%). CND presentation showed: hemiparesis, 72%; spasticity, 80%; ambulation, 72%; intellectual disability, 44%; autism, 16%; epilepsy, 12%; permanent vision and hearing impairment, 12% and 8%, respectively. Overall, 32% of presumed causative events happened before first CCS. Independent odds ratio for CND are age (days) at first CCS, 1.08 (CI 1.04-1.12; P , .001); highest plasma lactate before first CCS (mmol/L), 1.13 (CI 1.03-1.23; P = 0.008); and .1 CCS, 3.57 (CI 1.48-8.9; P = .005).CONCLUSIONS: CND is not uncommon among CCS survivors. The frequency of associated disabilities characterized in this study informs pediatricians caring for this vulnerable population. Shortening the waiting period and reducing preoperative plasma lactate levels at first CCS may assist in reducing the frequency of CND. WHAT'S KNOWN ON THIS SUBJECT:Neurodevelopmental outcomes after cardiac surgery in early life provide critical information for understanding and improving care. Studies show these children are at risk for arterial ischemic stroke and acquired brain injury; further characterization of motor impairment is needed. WHAT THIS STUDY ADDS:This study focuses on the presence of chronic neuromotor disabilities including cerebral palsy and motor impairments after acquired brain injury in children surviving early complex cardiac surgery, providing information on the frequency, characteristics, and predictors that may assist in prevention.

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Section: Figurementioning

confidence: 99%

Chronic Neuromotor Disability After Complex Cardiac Surgery in Early Life

Ricci¹,

Andersen

Joffe

et al. 2015

Pediatrics

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“…Postoperative hyperlactatemia as a result of tissue hypoperfusion is associated with high morbidity and mortality, and the serum or plasma lactate level in the intensive care unit (ICU) has prognostic value after pediatric cardiac surgery (Cheifetz et al 1997;Charpie et al 2000, Cheung et al 2005, Basaran et al 2006). In addition, hyperlactatemia during cardiopulmonary bypass (CPB) is an early predictor of morbidity and mortality in pediatric patients (Munoz et al 2000, Ranucci et al 2006.…”

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confidence: 99%

Intraoperative Plasma Lactate as an Early Indicator of Major Postoperative Events in Pediatric Cardiac Patients

Park

Kim

Byon

et al. 2012

Tohoku J. Exp. Med.

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Hyperlactatemia and unmeasured anions (UMA) have been suggested to be useful predictors of outcomes after pediatric cardiac surgery in the ICU. However, if we detect high-risk patient in the operating room, we could practice early intervention to decrease mortality and morbidity. The purpose of this study was to determine whether the intraoperative lactate or UMA levels can predict adverse outcomes in pediatric cardiac patients with undergoing cardiopulmonary bypass (CPB). We studied 102 patients with congenital heart disease. Arterial blood samples were obtained after inducing anesthesia, 5 min after weaning from CPB and after chest closure. Major adverse events (MAEs) were defined as cardiac compression, re-sternotomy due to hemodynamic instability, extra-corporeal membrane oxygenator support, creatinine levels greater than 2 mg/dL, or death. Patients were divided into MAE group (8 patients, 7.8%) and non-MAE group. Six patients with MAEs died. Importantly, the lactate levels (mmol/L) at weaning from CPB (4.19 vs 2.1; MAE group vs non-MAE group), chest closure (5.76 vs 2.39; MAE group vs non-MAE group) and the intraoperative increases in lactate levels were significantly higher in the MAE group than in the non-MAE group. However, there was no significant difference in the UMA levels or their changes between the groups. The increase in the lactate level from CPB weaning to chest closure was the best predictor of MAEs (AUC: 0.810). In conclusion, the intraoperative plasma lactate levels were more closely associated with MAEs, and they are more useful for predicting the outcome of pediatric cardiac patients than the UMA levels.

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“…35 Other factors that have been associated with adverse neurodevelopmental outcomes include low gestational age, low birth weight, presence of a genetic syndrome, and high pre-and post-operative lactate. 23,36,37 Surprisingly, the complexity of the underlying cardiac lesion and the duration of cardiopulmonary bypass and deep hypothermic cardiac arrest were not associated with developmental outcomes. 21 Recently, it has been recognized that more than half of newborns with CHD have clinical evidence of neurological abnormalities on examination before surgery and that these abnormalities are a significant risk factor for later neurodevelopmental impairment.…”

Section: Opportunities For Intervention: Etiology Of Neurodevelopmentmentioning

confidence: 97%

Preventing Brain Injury in Newborns With Congenital Heart Disease

Sherlock

McQuillen

Miller

2009

Stroke

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Miller, MDCM, MAS; on behalf of aCCENTBackground and Purpose-Newborns with congenital heart disease are at high risk for brain injury and adverse neurodevelopmental outcomes. MRI enables the objective determination of the severity of brain injury in critically ill newborns with congenital heart disease. We will rationalize the use of MRI as a surrogate for neurodevelopmental outcome and describe novel randomization techniques that can be used in trials in this population. Methods-This article describes the evidence for the use of MRI and the link with neurodevelopmental outcome established in newborns. We also discuss the use of adaptive randomization techniques for future clinical trials in newborns with congenital heart disease. These strategies will be highlighted using an example. Results-Brain injuries occur with high frequency in newborns with congenital heart disease. It is not until school age that the full extent of neurological sequelae becomes apparent and the rapid pace of innovation in neonatal cardiac surgery prevents timely evaluation of changes in care. MRI provides a timely, safe, and reliable outcome measure and has been extensively studied in newborns with other conditions in which the link between brain injury and neurodevelopmental outcome has been established. Clinical trials using MRI as an outcome measure as well as adaptive randomization can improve the efficiency of such trials. Conclusions-Clinical trials of brain protection are urgently needed in newborns with congenital heart disease given the unacceptable frequency of brain injury in this population; MRI provides an early surrogate marker of long-term neurodevelopmental outcome and adaptive randomization can be used to improve the efficiency of these clinical trials. Key Words: brain injury Ⅲ congenital heart disease Ⅲ MRI Ⅲ neurodevelopment Ⅲ randomized, controlled trials E xperts have called for large clinical trials in the prevention of pediatric strokes based on the example set by pediatric oncology groups; oncology clinical trials have vastly improved the survival and outcomes of pediatric oncology survivors. 1 The incidence of stroke in the newborn is 20 per 100 000 live births and leads to a high risk of significant long-term neurological impairments for survivors, 2 including cerebral palsy, 3 cognitive deficits, visual disturbances, and epilepsy. 4 MRI is increasingly being used to detect stroke in the newborn. A number of imaging features of stroke are now recognized as predictors of adverse neurodevelopmental outcome. 3,5 Newborns with congenital heart disease (CHD) are at increased risk for brain injury and adverse neurodevelopmental outcomes. High-resolution MRI and diffusion tensor imaging enable us to objectively determine the severity of brain injury in these newborns. Periventricular leukomalacia and neonatal strokes have both been reported to be the most significant lesions in terms of severity and incidence in infants that undergo CHD repair 6,7 ; modifiable risk factors have been identified for both giving the ho...

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Postoperative lactate concentrations predict the outcome of infants aged 6 weeks or less after intracardiac surgery: A cohort follow-up to 18 months

Abstract: Serial lactate determination accurately predicts survival and may help differentiate survivors with adverse outcome from those with intact neurodevelopment in early childhood.

Cited by 95 publications

References 26 publications

Chronic Neuromotor Disability After Complex Cardiac Surgery in Early Life

Chronic Neuromotor Disability After Complex Cardiac Surgery in Early Life

Intraoperative Plasma Lactate as an Early Indicator of Major Postoperative Events in Pediatric Cardiac Patients

Preventing Brain Injury in Newborns With Congenital Heart Disease

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