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Triiodothyronine Supplementation for Children Undergoing Cardiopulmonary Bypass: A Meta-Analysis
Monique R Radman1, April E Slee2, Eva M Marwali3
1Division of Cardiac Critical Care, Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, RC.2.820, Seattle, WA, 98105, USA. monique.radman@seattlechildrens.org.
Insights
Triiodothyronine (T3) repletion after cardiopulmonary bypass (CPB) shows potential benefits in specific pediatric groups. T3 supplementation appears safe and cost-effective, particularly in resource-limited settings with malnourished children.
Area of Science:
- Pediatric Endocrinology
- Cardiovascular Surgery
- Critical Care Medicine
Background:
- Pediatric responses to triiodothyronine (T3) repletion during and after cardiopulmonary bypass (CPB) vary significantly across different populations.
- Understanding these disparate responses is crucial for optimizing post-operative care in pediatric patients undergoing CPB.
Purpose of the Study:
- To evaluate the efficacy of triiodothyronine (T3) supplementation in improving clinical outcomes for children undergoing cardiopulmonary bypass (CPB).
- To analyze differences in T3 efficacy based on geographical setting (US vs. Indonesia) and patient characteristics.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) involving children aged 0-3 years undergoing CPB.
- Searched literature from 1/1/2000 to 1/31/2022, including 5 RCTs with 767 total subjects.
- Calculated Hazard Ratios (HR) for time to extubation (TTE), ICU length of stay (LOS), and hospital LOS, comparing T3 treatment groups.
Main Results:
- Overall, no significant difference in TTE was observed between T3-treated and control groups [HR 1.09 (CI, 0.94-1.26)].
- TTE numerically favored T3 in infants aged 1-5 months [HR 1.24 (CI, 0.97-1.60)].
- Significant benefits of T3 supplementation on hospital LOS [HR 1.30 (CI, 1.01-1.67)] and ICU LOS (p=0.046) were observed in Indonesia, but not in the US. Baseline thyroid function was lower in Indonesian subjects, potentially linked to malnutrition.
Conclusions:
- Triiodothyronine (T3) supplementation is a simple, inexpensive, and safe intervention for children undergoing CPB.
- T3 repletion demonstrates a beneficial effect on clinical outcomes, particularly in resource-limited settings like Indonesia, likely due to lower baseline thyroid function associated with malnutrition.
- Further research may elucidate the specific mechanisms behind these setting-dependent differences in T3 efficacy.
Abstract:
Specific pediatric populations have exhibited disparate responses to triiodothyronine (T3) repletion during and after cardiopulmonary bypass (CPB). Objective: To determine if T3 supplementation improves outcomes in children undergoing CPB. We searched randomized controlled trials (RCT) evaluating T3 supplementation in children aged 0-3 years undergoing CPB between 1/1/2000 and 1/31/2022. We calculated Hazard ratios (HR) for time to extubation (TTE), ICU length of stay (LOS), and hospital LOS. 5 RCTs met inclusion criteria with available patient-level data. Two were performed in United States (US) and 3 in Indonesia with 767 total subjects (range 29- 220). Median (IQR) age 4.1 (1.6, 8.0) months; female 43%; RACHS-1 scores: 1-1%; 2-55%; 3-27%; 4-13%; 5-0.1%; 6-3.9%; 54% of subjects in US vs 46% in Indonesia. Baseline TSH and T3 were lower in Indonesia (p < 0.001). No significant difference occurred in TTE between treatment groups overall [HR 1.09 (CI, 0.94-1.26)]. TTE numerically favored T3-treated patients aged 1-5 months [HR 1.24 (CI, 0.97-1.60)]. TTE HR for the Indonesian T3 group was 1.31 (CI, 1.04-1.65) vs. 0.95 (CI, 0.78-1.15) in US. The ICU LOS HR for the Indonesian T3 group was 1.19 vs. 0.89 in US (p = 0.046). There was a significant T3 effect on hospital LOS [HR 1.30 (CI, 1.01-1.67)] in Indonesia but not in US [HR 0.99 (CI, 0.78-1.23)]. T3 supplementation in children undergoing CPB is simple, inexpensive, and safe, showing benefit in resource-limited settings. Differences in effects between settings likely relate to depression in baseline thyroid function often associated with malnutrition.
