Prophylactic corticosteroids for paediatric heart surgery with cardiopulmonary bypass

Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the benefits and harms of prophylactic corticosteroids in children between birth and 18 years of age undergoing cardiac surgery with cardiopulmonary bypass. B A C K G R O U N D Description of the condition Paediatric heart surgery outcomes have improved markedly over time as a result of marginal gains in training, technology and safety systems (Brown 2015; Hoashi 2015; Jacobs 2016; NICOR 2016). This improvement has been particularly notable in the last 20 years: the publication of heart surgery outcomes after the Kennedy Inquiry in the UK has been associated with a large increase in survival for risk-adjusted surgery (Kennedy 2001; Grant 2013). This has been mirrored worldwide (Brown 2015; Hoashi 2015; Jacobs 2016). One area where there is still controversy is corticosteroid use. Paediatric heart surgery with the use of cardiopulmonary bypass results in a systemic inflammatory response; corticosteroids have been widely used to mitigate the potential deleterious effects of this response. The surgical intervention for which corticosteroids are used includes a variety of surgeries performed on the heart and great vessels. In most cases this procedure aims to correct congenital heart diseases (i.e. heart malformations that the child is born with). In most cases (78% in the UK) (NICOR 2016), surgery will take place with the use Cardio-Pulmonary By-1 Prophylactic corticosteroids for paediatric heart surgery with cardiopulmonary bypass (Protocol)

Critical Illness-Related Corticosteroid Insufficiency (CIRCI) After Pediatric Cardiac Surgery

“…23 A 2020 Cochrane review (13 studies) and a more recent meta-analysis (10 trials) on the topic both concluded that prophylactic corticosteroids probably reduce the length of postoperative hospital length of stay but likely do not alter mortality or overall morbidity after congenital cardiac surgery. 5,29 Limitations and Future Directions Our report, however, has limitations. Source studies consist of a limited number of randomized control trials (RCTs) that are exclusively single-center works with small sample sizes.…”

“…18,22,24 Two recent meta-analyses echoed these observations, finding the most benefit in neonates and surgeries with STS risk score >3. 5,23 2. Clinical criteria: Table 2 shows general criteria for hemodynamic instability.…”

“…18,22,24 Two recent meta-analyses echoed these observations, finding the most benefit in neonates and surgeries with STS risk score >3. 5,23 Clinical criteria: Table 2 shows general criteria for hemodynamic instability. 2 Biochemical criteria: Most studies have measured basal or peak cortisol levels followed by increment of change with exogenous ACTH administration pre- and/or post-CPB. Multiple studies have used highly variable basal cortisol cutoffs ranging from 5 to 15 µg/dL to diagnose CIRCI after CPB.…”

“…There is an extreme paucity of data on CIRCI after CPB, and the current limited literature does not support the routine use of corticosteroids before or after CPB. 5,6 However, a few small studies have demonstrated lower cortisol levels and blunted Adrenocorticotropic Hormone (ACTH) response in a subgroup of patients with fluid- and catecholamine-refractory hypotension with dramatically improved hemodynamics after the administration of exogenous steroids. 3,7 Unfortunately, optimal identification of this subset of patients is difficult, and a single diagnostic and therapeutic approach remains elusive.…”

Mechanical ventilation core outcome set uptake in Cochrane systematic reviews: A cross‐sectional study

“…We identified 233 reviews and protocols. We excluded 197 records because they did not focus on mechanically ventilated patients and finally included 36 records [17–51]. See the flow diagram in Figure 1.…”