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Coagulopathic bleeding is a major complication of pediatric cardiac surgery. Investigating perioperative dynamics of thrombin generation and antithrombin (AT) activity might provide more insight into the underlying mechanisms of coagulopathy. This can help develop a targeted hemostatic approach in the future. The authors hypothesized that there is a decline in both thrombin generation and AT activity in infants undergoing cardiopulmonary bypass (CPB).Prospective observational study.Single academic medical center.Infants10 kg of weight undergoing cardiac surgery with CPB.Blood specimen collection and testing.The authors performed assays of thrombin generation and AT activity on the samples of platelet-poor plasma of 25 infants, repeating them at 3 points: before CPB and heparinization, after separation from CPB and protamine administration, and after chest closure. The authors observed a statistically significant decline in thrombin generation shortly after separation from CPB compared with baseline. The geometric mean for lag time was prolonged (4.0 v 5.5 minutes, p = 0.013), and peak thrombin and the net amount of generated thrombin declined almost 3-fold (80.7 v 25.1 nmol, p0.001; 1264 v 476 nmol, p0.001, respectively). This was accompanied by a decline in AT activity (59.8 v 50.1, p = 0.001). After platelet and cryoprecipitate transfusion, at the case conclusion AT activity had recovered marginally (59.8 v 55.4, p = 0.042), but thrombin generation remained reduced.In pediatric patients10 kg undergoing cardiac surgery with CPB, thrombin generation and AT activity decline and do not recover completely after transfusion of platelets and cryoprecipitate.

OBJECTIVES To provide a comparative analysis of conventional heparin-versus bivalirudin-based systemic anticoagulation in adult and pediatric patients supported on extracorporeal membrane oxygenation. DESIGN Retrospective chart review study of adult and pediatric patients receiving extracorporeal membrane oxygenation from January 1, 2014, to October 1, 2019. SETTING A large, high-volume tertiary referral adult and pediatric extracorporeal membrane oxygenation center. PATIENTS Four hundred twenty-four individuals requiring extracorporeal membrane oxygenation support and systemically anticoagulated with either unfractionated heparin (223 adult and 65 pediatric patients) or bivalirudin (110 adult and 24 pediatric patients) were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Digital data abstraction was used to retrospectively collect patient details. The majority of both groups were cannulated centrally (67%), and the extracorporeal membrane oxygenation type was predominantly venoarterial (84%). The adult bivalirudin group had a greater occurrence of heparin-induced thrombocytopenia (12% vs 1%; p < 0.01) and was more likely to require postcardiotomy extracorporeal membrane oxygenation (36% vs 55%; p < 0.01). There were no statistical differences between the groups in regards to age, sex, and extracorporeal membrane oxygenation initiation location. The main finding was a reduced mortality in the adult bivalirudin group (odds ratio, 0.39; p < 0.01), whereas no difference was noted in the pediatric group. A significant reduction in the composite transfusion requirement in the first 24 hours was noted in the pediatric bivaluridin group with an odds ratio of 0.28 (p = 0.02). Groups did not differ in regard to laboratories per day, anticoagulant dose adjustments, or ischemic complications. CONCLUSIONS When compared with heparin-based systemic anticoagulation, bivalirudin demonstrated feasibility and safety as established by the absence of increases in identifiable adverse outcomes while manifesting substantial improvements in hospital mortality in adult patients. Further studies are necessary to corroborate these findings and further elucidate the role of bivalirudin during extracorporeal membrane oxygenation support.

BACKGROUND High levels of vasoactive inotrope support (VIS) after congenital heart surgery are predictive of morbidity in pediatric patients. We sought to discern if this relationship applies to adults with congenital heart disease (ACHD). METHODS We retrospectively studied adult patients (≥18 years old) admitted to the intensive care unit after cardiac surgery for congenital heart disease from 2002 to 2013 at Mayo Clinic. Vasoactive medication dose values within 96 hours of admission were examined to determine the relationship between VIS score and poor outcome of early mortality, early morbidity, or complication related morbidity. RESULTS Overall, 1040 ACHD patients had cardiac surgery during the study time frame; 243 (23.4%) met study inclusion criteria. Sixty-two patients (25%), experienced composite poor outcome [including eight deaths within 90 days of hospital discharge (3%)]. Thirty-eight patients (15%) endured complication related early morbidity. The maximum VIS (maxVIS) score area under the curve was 0.92 (95% CI: 0.86-0.98) for in-hospital mortality; and 0.82 (95% CI: 0.76-0.89) for combined poor clinical outcome. On univariate analysis, maxVIS score ≥3 was predictive of composite adverse outcome (OR: 14.2, 95% CI: 7.2-28.2; P

Mechanical circulatory support (MCS) has become an indispensable tool in the management of children with impending respiratory and cardiac failure. Though extracorporeal membrane oxygenation (ECMO) was classically the only form of support available to pediatric patients, considerable advances have allowed ventricular assist devices (VADs) to become increasingly utilized in children. This review provides an update of recent advances in ECMO and VAD management in children.The options for mechanical support in infants and small children with end-stage heart failure are limited. As such, the greatest advances in the past decade have come in the successful adoption of the Berlin Heart EXCOR device, with a marked improvement in survival to transplant over ECMO. Further advances have been made in the use of adult VADs in children. For instance, the HeartWare HVAD has been utilized in children as young as 3 years of age, despite being designed for use in adult patients.The availability of mechanical support options for children remains limited to ECMO and a small number of VADs. While outcomes of VAD support in pediatric patients have been promising, further study in smaller and more complex pediatric patients is necessary.

Mechanical circulatory support (MCS) has become a critical tool for managing children with impending respiratory and cardiac failure. Although extracorporeal membrane oxygenation was classically the only form of support available for children, ventricular assist devices (VADs) are increasingly used in children. Common indications for MCS include an inability to oxygenate or ventilate that progresses to respiratory failure and cardiac failure secondary to anatomic abnormalities or primary myocardial failure. The most common contraindication for MCS is death in the near future. This contraindication may include patients with other fatal systemic diseases, patients at high risk of bleeding, or extreme prematurity. Important recent advances in VAD technology include the introduction of the Berlin Heart EXCOR device, as well as the successful use of devices for adults (e.g., the Heartmate and Heartware VADs) in larger children. Although outcomes of VAD support in children have been promising, further studies of smaller and clinically more complex children are required.

In severe pediatric acute respiratory distress syndrome, data are lacking on methods to measure and set optimal positive end-expiratory pressure. We present a 2-year-old girl with Trisomy 21 who developed severe pediatric acute respiratory distress syndrome and refractory hypoxemia from human metapneumovirus pneumonia. Esophageal manometry was utilized to measure transpulmonary pressure, and positive end-expiratory pressure was increased to 19 cm H2O, resulting in rapid improvement in oxygenation. Hemodynamics remained adequate without intervention. The patient improved and survived without sequelae. Our case suggests that transpulmonary pressure monitoring should be studied as an adjunct to improve outcomes in pediatric acute respiratory distress syndrome.

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease with the majority of patients requiring additional surgical interventions in adulthood. We examined preoperative imaging in adult TOF patients to identify factors impacting early postoperative morbidity and

Improved survival after cardiac arrest has placed greater emphasis on neurologic resuscitation. The purpose of this pilot study was to evaluate the relationship between cerebrovascular autoregulation and neurologic outcomes after pediatric cardiac arrest.Children resuscitated from cardiac arrest had autoregulation monitoring during the first 72h after return of circulation with an index derived from near-infrared spectroscopy in a pilot study. The range of mean arterial blood pressure (MAP) with optimal vasoreactivity (MAPOPT) was identified. The area under the curve (AUC) of the time spent with MAP below MAPOPT and MAP deviation below MAPOPT was calculated. Neurologic outcome measures included placement of a new tracheostomy or gastrostomy, death from a primary neurologic etiology (brain death or withdrawal of support for neurologic futility), and change in the Pediatric Cerebral Performance Category score (ΔPCPC).Thirty-six children were monitored. Among children who did not require extracorporeal membrane oxygenation (ECMO), children who received a tracheostomy/gastrostomy had greater AUC during the second 24h after resuscitation than those who did not (P=0.04; n=19). Children without ECMO who died from a neurologic etiology had greater AUC during the first 48h than did those who lived or died from cardiovascular failure (P=0.04; n=19). AUC below MAPOPT was not associated with ΔPCPC when children with or without ECMO were analyzed separately.Deviation from the blood pressure with optimal autoregulatory vasoreactivity may predict poor neurologic outcomes after pediatric cardiac arrest. This experimental autoregulation monitoring technique may help individualize blood pressure management goals after resuscitation.

Summary Over the past decade, numerous preclinical and retrospective human studies have reported that the provision of anesthetic and sedative agents to infants and children may be associated with adverse neurodevelopmental outcomes. These data have gained widespread attention from professional and regulatory agencies, including the public at large. As such, pediatric anesthesiologists are being increasingly questioned by parents about the risks of anesthetic agents on their children's neurocognitive development. To impart a framework from which anesthesiologists may address the apprehensions of parents who actively bring up this issue, we review the data supporting anesthetic neurotoxicity and discuss its strengths and limitations. As many parents are not yet aware and do not actively raise these concerns, we also discuss whether such a conversation should be undertaken as a part of the consent process.

Objective: To investigate the impact of human metapneumovirus on morbidity and mortality outcomes in children with severe viral respiratory infection. Design: Retrospective cohort study. Setting: ICU, either PICU or cardiac ICU, at three urban academic tertiary care children’s hospitals. Patients: All patients admitted to an ICU with laboratory-confirmed human metapneumovirus infection between January 2010 and June 2011. Interventions: We captured demographic and clinical data and analyzed associated morbidity and mortality outcomes. Measurements and Main Results: There were 111 patients with laboratory-confirmed human metapneumovirus admitted to an ICU at one of the three participating institutions during the period of study. The median hospital length of stay was 7 days (interquartile range 4–18 days) and median ICU length of stay was 4 days (interquartile range 1–10 days). Ten patients (9%) did not survive to discharge. Predisposing factors associated with increased mortality included female gender (p = 0.002), presence of a chronic medical condition (p = 0.04), and hospital acquisition of human metapneumovirus infection (p = 0.006). Adjusting for female gender, chronic medical conditions, hospital acquisition of infection and severity of illness score, logistic regression analysis demonstrated that female gender, hospital acquisition of infection, and chronic medical conditions each independently increased the odds of mortality (odds ratios 14.8, 10.7, and 12.7, respectively). Conclusions: Analysis of our results suggests that there is substantial morbidity and mortality associated with severe viral respiratory infection due to human metapneumovirus in children. Female gender, hospital acquisition of human metapneumovirus infection, and presence of chronic medical conditions each independently increases mortality. The burden of illness from human metapneumovirus on the ICU in terms of resource utilization may be considerable.