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Steroid use before pediatric cardiac operations using cardiopulmonary bypass: an international survey of 36 centers
Paul A Checchia1, Ronald A Bronicki, John M Costello
1Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA.
Insights
Steroid use before pediatric cardiac surgery is common, but practices vary widely in type, dose, and timing. Further research is needed to establish optimal steroid administration protocols for cardiopulmonary bypass.
Area of Science:
- Pediatric Cardiac Surgery
- Cardiopulmonary Bypass
- Inflammatory Response Modulation
Background:
- Steroids can reduce inflammation and myocardial injury during pediatric cardiac operations.
- Current practices for steroid administration before these procedures are not standardized.
Purpose of the Study:
- To investigate the variability in steroid administration practices among pediatric cardiac surgical centers.
- To identify current protocols for steroid use before cardiopulmonary bypass in pediatric cardiac surgery.
Main Methods:
- A questionnaire survey was distributed to members of the Pediatric Cardiac Intensive Care Society.
- The survey collected data on steroid administration protocols from participating pediatric intensive care units.
Main Results:
- Nearly all surveyed centers (97%) use steroids before cardiopulmonary bypass.
- However, only 40% administer steroids in every case, with significant variability in type, dose, route, and timing.
- Steroid regimens differ based on patient age, surgeon preference, and anticipated procedure length.
Conclusions:
- Steroid administration before pediatric cardiopulmonary bypass is inconsistent across centers.
- The wide variation in practices highlights the need for a large, multi-center clinical trial.
- Such a trial is essential to determine the optimal risks and benefits of steroid use in this patient population.
Objective:
Steroid administration before pediatric cardiac operations using cardiopulmonary bypass has been shown to modulate the inflammatory response and reduce myocardial injury. We hypothesized that current steroid administration practices among pediatric cardiac surgical centers are highly variable.
Design:
Questionnaire survey.
Setting:
Pediatric intensive care units.
Subjects:
All members of the Pediatric Cardiac Intensive Care Society.
Interventions:
A self-administered survey was sent to >130 members and 70 institutions participating in the Pediatric Cardiac Intensive Care Society.
Measurements And Main Results:
Thirty-six questionnaires were returned: 14 international and 22 domestic centers. Cumulatively, these centers treat >11,000 pediatric cardiac patients per year. Ninety-seven percent (35 of 36) of these centers report the use of steroids before cardiopulmonary bypass, yet only 40% (14 of 35) administer steroids with every case. Of the 21 centers that selectively use steroids, 12 do so only for neonates, five administer steroids based on surgeon preference, and four administer steroids for cases anticipated to involve bypass time >2 hrs or deep hypothermic circulatory arrest. Of the 35 centers using steroids, 11 deliver a single dose in the circuit prime, 18 administer a single dose to the patient, and six give multiple doses. The timing of the steroid dose to the patient is variable; 12 centers administer a dose on induction of anesthesia; six centers administer the dose 2-12 hrs before operation. Regimens in the six centers using multiple doses of steroids before cardiopulmonary bypass are as follows: administration at induction and in the prime (two centers); 12 hrs preoperatively and at induction (one center); prime, induction, and 6 hrs preoperatively (one center); prime and midnight preoperatively (one center); and prime plus 2 and 8 hrs preoperatively (one center). Eight centers continue steroid administration following bypass.
Conclusion:
Although nearly all centers surveyed administer steroids before cardiopulmonary bypass, the type, dosing, route, and timing of administration are highly variable. The inconsistencies in these data and the pediatric literature would support the undertaking of a large, multiple-center clinical trial to evaluate the risks and benefits of steroid administration before pediatric cardiopulmonary bypass.
