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Neurosurgical intervention in children with ventricular assist devices: A single-center case series review
Jane Yu1, Jenna Murray2, Chandra Ramamoorthy3
1Department of Pediatric Anesthesiology, Lurie Children's Hospital, Chicago, IL, USA.
Insights
Pediatric patients on ventricular assist devices (VAD) experiencing neurological events like bleeding or stroke require specialized neurosurgical care. Operative management improved survival outcomes compared to less invasive procedures.
Area of Science:
- Pediatric Cardiac Surgery
- Pediatric Neurosurgery
- Mechanical Circulatory Support
Background:
- Neurological complications, including intracranial hemorrhage and ischemic stroke, are common and severe in pediatric patients with ventricular assist devices (VAD).
- Current management guidelines for these neurological emergencies in VAD patients are lacking, necessitating operative interventions for significant injuries.
Purpose of the Study:
- To describe the perioperative management strategies for pediatric patients undergoing neurosurgical procedures for major intracranial bleeds or ischemic strokes while supported by VADs.
- To evaluate the outcomes of neurosurgical interventions in this high-risk pediatric population.
Main Methods:
- Retrospective review of a single-center database for pediatric VAD patients who underwent neurosurgical procedures for intracranial hemorrhage or ischemic stroke between April 2014 and January 2020.
- Collection of data on patient demographics, preoperative medical management, intraoperative anesthetic care, and postoperative outcomes.
Main Results:
- Five neurosurgical interventions were performed in pediatric VAD patients: four for intracranial hemorrhages and one for ischemic stroke.
- Patients with hemorrhages often required anticoagulation reversal and platelet transfusions; operative procedures, unlike external ventricular drains, were associated with survival to discharge.
- Patients undergoing operative procedures received intensive hemodynamic monitoring and support, with one requiring massive blood transfusion.
Conclusions:
- Perioperative management of pediatric VAD patients with neurological complications requires careful attention to hemodynamic stability, bleeding risks, and VAD function.
- A systematic, multidisciplinary approach is crucial for optimizing outcomes in these complex cases.
- Surgical intervention appears to offer better survival prospects than less invasive drainage procedures for severe neurological events in VAD patients.
Background:
The incidence of neurological complications related to ventricular assist devices (VAD) remains high and includes life-threatening conditions such as intracranial hemorrhage or ischemic stroke. Although no definitive management guidelines exist, operative interventions may be required for major neurological injuries.
Aims:
This case series describes the perioperative management of children at a single center who underwent neurosurgical procedures for major intracranial bleeds or ischemic strokes while on VAD support.
Methods:
A database review identified all pediatric VAD patients who underwent a neurosurgical procedure for an intracranial hemorrhage or ischemic stroke from April 2014 to January 2020. Data regarding patient characteristics, preoperative medical management, intraoperative anesthetic management, and postoperative outcomes were collected using retrospective chart review.
Results:
Ninety VADs were implanted in 78 patients. Five neurosurgical interventions were performed: four for intracranial hemorrhages and one for an ischemic stroke. All four patients with hemorrhages were receiving anticoagulation at the time of their event and the three patients on warfarin received emergent reversal with prothrombin concentrate complex and vitamin K. Three patients also received pre-procedural platelet transfusions. Two of the five procedures were emergent bedside external ventricular drain placements, and three were surgical operations. All three patients who underwent operative procedures received invasive hemodynamic monitoring and were supported with a combination of inotropes and afterload reduction. One patient required a massive blood product transfusion. The two patients who underwent external ventricular drain placement had no further surgical interventions and died from the severity of their neurological injuries. All three patients who underwent operative procedures survived to transplantation and discharge home.
Conclusions:
Perioperative concerns for the anesthesiologist include VAD hemodynamic management, bleeding, VAD thrombosis, and prevention of secondary brain injury. A systematic, multidisciplinary approach to management is paramount to attain favorable outcomes.
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