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Implantation of the Syncardia Total Artificial Heart
Published on: July 18, 2014
Children undergoing heart transplant are at increased risk for postoperative vasodilatory shock
James S Killinger1, Daphne T Hsu, Charles L Schleien
1Department of Pediatrics, Division of Critical Care Medicine, Columbia University, College of Physicians and Surgeons, Bronx, NY, USA. jkilling@montefiore.org
Insights
Post-cardiopulmonary bypass vasodilatory shock (VDS) is rare in children, affecting 3%. However, children undergoing heart transplantation (HT) or ventricular assist device (VAD) placement face a significantly higher risk of developing this condition.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular surgery
- Pediatric intensive care
Background:
- Vasodilatory shock (VDS) can occur after cardiopulmonary bypass (CPB) in children.
- Understanding the incidence and characteristics of post-CPB VDS is crucial for pediatric critical care.
Purpose of the Study:
- To determine the incidence of vasodilatory shock (VDS) in children following cardiopulmonary bypass (CPB).
- To describe the clinical syndrome of post-CPB VDS in the pediatric population.
Main Methods:
- Prospective, observational study design.
- Evaluation of 300 children undergoing CPB in pediatric and neonatal intensive care units.
- Clinical assessment for evidence of VDS post-CPB.
Main Results:
- The overall incidence of post-CPB VDS was 3%.
- Children who developed VDS had higher peak lactate and blood urea nitrogen, lower urine output, and fewer ICU-free days.
- Univariate predictors included heart transplantation (HT)/ventricular assist device (VAD) placement, cardiomyopathy, older age, longer CPB time, and preoperative ventricular dysfunction.
- Heart transplantation/ventricular assist device placement was the only independent predictor for VDS development.
Conclusions:
- Post-CPB VDS is uncommon in the general pediatric population undergoing CPB.
- Children undergoing heart transplantation or ventricular assist device placement are at a substantially higher risk for developing post-CPB VDS.
- Recognizing the low overall incidence, except in the HT/VAD population, can guide therapeutic strategies in pediatric post-CPB patients.
Objective:
To determine the incidence of vasodilatory shock (VDS) in children after cardiopulmonary bypass (CPB), and to describe this syndrome of post-CPB VDS in children.
Design:
Prospective, observational.
Setting:
Pediatric and neonatal intensive care units in a tertiary care, children's hospital.
Patients:
Three hundred children undergoing CPB.
Intervention:
None.
Measurements And Main Results:
Three hundred subjects undergoing CPB were evaluated for clinical evidence of VDS following CPB. The incidence of post-CPB VDS was 3%. Characteristics of children who developed VDS: higher peak lactate (6.2 +/- 2.6 vs. 3.0 +/- 2.1 mmol/L; p = 0.0002), higher peak serum blood urea nitrogen (18.5 +/- 4.6 vs. 15.6 +/- 7.2 mg/dL; p = 0.04), lower urine output (1.7 +/- 0.8 vs. 2.6 +/- 0.2 mL/kg/hr; p = 0.04), and fewer intensive care unit free days (14.9 +/- 9.0 vs. 21.1 +/- 7.2 days; p = 0.01). Univariate predictors for the development of post-CPB VDS included children who had heart transplantation (HT) (relative risk [RR], 9.8; 95% confidence interval [CI], 2.7-35.2) or ventricular assist device (VAD) placed (RR, 17.9; 95% CI, 3.8-84.1), a cardiomyopathy diagnosis (RR, 8.5; 95% CI, 2.3-31), age >12 years (RR, 4.5; 95% CI, 1.2-17.0), CPB time >180 minutes (RR, 7.1; 95% CI, 1.9-26.2), and preoperative ventricular dysfunction (RR, 3.7; 95% CI, 1.0-13.4). By stratified analysis, the only independent predictor for the development of VDS was undergoing HT/VAD.
Conclusions:
Post-CPB VDS is uncommon in children. However, children who undergo HT or VAD placement are at high risk for developing post-CPB VDS. Recognition that the overall incidence of post-CPB is low-except in the HT/VAD population-may help guide therapy in the pediatric post-CPB patient.
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