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Effect of Trendelenburg head position during cardiac deairing on cerebral microemboli in children: a randomized
R A Rodriguez1, G Cornel, N A Weerasena
1Division of Cardiovascular Surgery, the Departments of Surgery, Biostatistics, and Anaesthesia, Children's Hospital of Eastern Ontario, CHEO Research Institute and University of Ottawa, Ottawa, Ontario, Canada. Rodriguez@CHEO.ON.CA
Insights
Head position during cardiac deairing does not impact cerebral microemboli in children. Higher microembolic counts and ECG changes correlate with surgeon confidence in deairing effectiveness.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Neurosonology
Background:
- Cerebral microemboli are a concern during cardiac surgery in children.
- Effective deairing is crucial to minimize embolic events.
- The role of head positioning in deairing efficacy is not well-established.
Purpose of the Study:
- To evaluate the effect of head position (Trendelenburg vs. horizontal) during cardiac deairing on cerebral microemboli detected by Doppler ultrasonography in children.
- To assess the association between cerebral microembolic counts and the surgeon's clinical assessment of deairing efficacy.
Main Methods:
- Prospective randomized study of 128 children undergoing cardiac surgery with cardiopulmonary bypass.
- Children were randomized to Trendelenburg (-15°) or horizontal (0°) head positions during deairing.
- Cerebral microemboli (high-intensity transient signals) were monitored using transcranial Doppler ultrasonography; deairing efficacy was assessed by surgeons using a 5-point scale.
Main Results:
- High-intensity transient signals (HITS) were detected in 97% of patients.
- Head position or surgeon did not significantly affect HITS rates.
- HITS occurrence during the residual interval was lower in simpler repairs (Group I) compared to complex ones (Group II).
- Increased HITS and electrocardiographic alterations correlated with poorer clinical deairing assessments (P <.01).
Conclusions:
- Trendelenburg head position does not reduce cerebral microembolic load compared to horizontal positioning during cardiac deairing in children.
- Higher cerebral microembolic counts and electrocardiographic changes are associated with reduced surgeon confidence in deairing effectiveness.
Objectives:
We prospectively evaluated the effects of head position during cardiac deairing on the Doppler ultrasonography-detected cerebral microemboli in children and the association between the embolic counts and the clinical assessment of deairing.
Methods:
Children requiring exposure of the systemic ventricle under cardiopulmonary bypass were randomized to Trendelenburg (-15 degrees ) and horizontal (0 degrees ) head positions during and after standard surgical deairing. Complexity of repair was categorized as follows: group I consisted of single simple lesions, and group II consisted of multiple complex lesions. Transcranial Doppler ultrasonography identified high-intensity transient signals in the right middle cerebral artery within the first 5 minutes after aortic declamping (release) and from this ending period until cardiopulmonary bypass termination (residual). Electrocardiographic alterations after deairing were documented. A predefined 5-point scale was used by the surgeon for blinded assessment of deairing.
Results:
High-intensity transient signals were identified in 97% of 128 patients (aged 5 days to 17 years). The median total high-intensity transient signal count was 60 (25th-75th quartiles, 14-189). Head position or surgeon did not affect the rate of high-intensity transient signals (P >.20). During the residual interval, occurrence of HITS in group I was less than that in group II (P <.05), but there was no difference at release. The incidence of high-intensity transient signals and electrocardiographic alterations correlated with the clinical assessment of deairing (P <.01).
Conclusions:
Trendelenburg head position as a complement of cardiac deairing in children does not decrease the cerebral microembolic load compared with the horizontal head position. The cerebral microembolic count and the occurrence of electrocardiographic alterations usually increases when the surgeon is less confident in the efficacy of deairing.
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