Little is known about practitioner preference, the availability of technology, and variability in practice with respect to hemodynamic monitoring and vasoactive drug use after congenital heart surgery. The aim of this study was to characterize current hospital practices related to the management of low cardiac output syndrome (LCOS) across Italy.
Methods:
We issued a 22-item questionnaire to 14 Italian hospitals performing pediatric cardiac surgery.
Results:
Electrocardiogram, invasive blood pressure, central venous pressure, pulse oximetry, diuresis, body temperature, arterial lactate, and blood gas analysis were identified as routine in hemodynamic monitoring. With regard to advanced hemodynamic monitoring, pulmonary arterial catheter and transpulmonary thermodilution were available in 43% of the centers, uncalibrated pulse contour methods in 29% of the centers, and transesophageal/transthoracic echocardiograms in all of the centers. Dopamine added to milrinone was the most frequent drug regimen for LCOS prevention after cardiopulmonary bypass. Overall, 86% of centers used milrinone alone as the initial treatment for LCOS with elevated systemic vascular resistances and levosimendan, the second preferred choice. In cases of LCOS with low vascular resistance, epinephrine was the first choice (10 centers), dopamine was the second choice (4 centers), followed by vasopressin and norepinephrine (3 centers). For treatment of LCOS with elevated pulmonary resistances, milrinone was the first choice (eight centers), followed by inhaled nitric oxide (five centers).
Conclusions:
The survey shows that advanced hemodynamic monitoring is rarely performed. The most commonly used vasoactive drugs are milrinone, levosimendan, dopamine, epinephrine, vasopressin, and norepinephrine. Guidelines on the topic are warranted.
WernovskyGWypijDJonasRA. Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants. A comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation. 1995;92(8):2226–2235. doi:10.1161/01.CIR.92.8.2226.
4.
AlgarniKDMagantiMYauTM. Predictors of low cardiac output syndrome after isolated coronary artery bypass surgery: trends over 20 years. Ann Thorac Surg. 2011;92(5):1678–1684. doi:10.1016/j.athoracsur.2011.06.017.
5.
TweddellJSGhanayemNSHoffmanGM. All this monitoring…what’s necessary, what’s not?Semin Thorac Cardiovasc Surg Pediatr Card Surg Ann. 2014; 17(1):81–90. doi:10.1053/j.pcsu.2014.01.010.
6.
BoehneMBaustertMPaetzelV. Determination of cardiac output by ultrasound dilution technique in infants and children: a validation study against direct Fick principle. Br J Anaesth. 2014;112(3):469–476. doi:10.1093/bja/aet382.
7.
HoffmanTMWernovskyGAtzAM. Efficacy and safety of milrinone in preventing low cardiac output syndrome in infants and children after corrective surgery for congenital heart disease. Circulation. 2003;107(7):996–1002. doi:10.1161/01.CIR.0000051365.81920.28.
8.
VogtWLäerS. Prevention for pediatric low cardiac output syndrome: results from the European survey EuLoCOS-Paed. Paediatr Anaesth. 2011;21(12):1176–1184. doi:10.1111/j.1460-9592.2011.03683x.
9.
RothSJAdatiaIPearsonGD. Summary proceedings from the cardiology group on postoperative cardiac dysfunction. Pediatrics. 2006;117(3):S40–S46. doi:10.1542/peds.2005-0620G.
10.
PasqualiSKHallMSlonimAD. Off-label use of cardiovascular medications in children hospitalized with congenital and acquired heart disease. Circ Cardiovasc Qual Outcomes. 2008;1(2):74–83. doi:10.1161/CIRCOUTCOMES.108.787176.
11.
VogtWLäerS. Treatment for paediatric low cardiac output syndrome: results from the European EuLoCOS-Paed survey. Arch Dis Child. 2011;96(12):1180–1186. doi:10.1136/archdischild-2011-300370.
12.
DillmanDA. Mail and internet surveys—the tailored design method, 2nd ed. New York, NY: Wiley; 2007.
13.
LeoneMValletBTeboulJLMateoJBastienOMartinC. Survey of the use of catecholamines by French physicians. Intensive Care Med. 2004;30(5):984–988. doi:10.1007/s00134-004-2172-1.
14.
KastrupMMarkewitzASpiesC. Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiol Scand. 2007;51(3):347–358. doi:10.1111/j.1399-6576.2006.01190.
15.
TengSKaufmanJPanZCzajaAShockleyHda CruzE. Continuous arterial pressure waveform monitoring in pediatric cardiac transplant, cardiomyopathy and pulmonary hypertension patients. Intensive Care Med. 2011;37(8):1297–1301. doi:10.1007/s00134-011-2252-y.
16.
GidwaniUMolantyBChatterjieeK. The pulmonary artery catheter. A critical reappraisal. Cardiol Clin. 2013;31(4):545–565. doi:10.1016/j.ccl.2013.07.008.
17.
SaxenaRDurwardAPuppalaNKMurdochIATibbySM. Pressure recording analytical method for measuring cardiac output in critically ill children: a validation study. Br J Anaesth. 2013;110(3):425–431. doi:10.1093/bja/aes420.
18.
TibbySMHatherillMMarschMJMurdochIA. Clinicians’ abilities to estimate cardiac index in ventilated children and infants. Arch Dis Child. 1997;77(6):516–518. doi:10.1136/adc.77.6.516.
19.
BrierleyJCarcilloJAChoongK. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;37(4):666–688. doi:10.1097/CCM.0b013e31819323c6.
20.
RossiAFChecchiaPALopezLSeidenHSBurkeRP. Web-based survey of current trends in hemodynamic monitoring after congenital heart surgery. World J Pediatric Cong Heart Surg. 2011;3(3):301–309.
21.
RossiAFKhanDMHannanRBolivarJZaidenweberMBurkeR. Goal-directed medical therapy and point-of-care testing improve outcomes after congenital heart surgery. Intensive Care Med. 2005;31(1):98–104.
22.
ChakravartiSSrivastavaSMittnachtAJ. Near infrared spectroscopy (NIRS) in children. Semin Cardiothorac Vasc Anesth. 2008;12(1):70–79.
23.
ChakravartiSBMittnachtAJKatzJC. Multisite near-infrared spectroscopy predicts elevated blood lactate level in children after cardiac surgery. J Cardiothorac Vasc Anesth. 2009;23(5):663–667.
24.
RicciZGaristoCFaviaI. Cerebral NIRS as a marker of superior vena cava oxygen saturation in neonates with congenital heart disease. Pediatr Anaesth. 2010;20(11): 1040–1045.
25.
de BoodeWP. Cardiac output monitoring in newborns. Early Hum Dev. 2010;86(3):143–148. doi:10.1016/j.earlhumdev.2010.01.032.
26.
FaklerUPauliChBallingG. Cardiac index monitoring by pulse contour analysis and thermodilution after pediatric cardiac surgery. J Thorac Cardiovasc Surg. 2007;133(1):224–228. doi:10.1016/j.jtcvs.2006.07.038
27.
Gil-AntonJLópez-BayónJLópez-FernándezYMorteruelEPérez-EstevezELópez-HerceJ. Cardiac index monitoring by femoral arterial thermodilution after cardiac surgery in children. J Crit Care. 2014;29(6):1132.e1-1132.e4. doi:10.1016/j.jcrc.2014.06.004.
28.
LintonRAJonasMMTibbySM. Cardiac output measured by lithium dilution and transpulmonary thermodilution in patients in a paediatric intensive care unit. Intensive Care Med. 2000;26(10):1507–1511. doi:10.1007/s001340051347.
29.
UrbanoJLópezJGonzálezR. Measurement of cardiac output in children by pressure-recording analytical method. Pediatr Cardiol. 2015;36(2):358–364. doi:10.1007/s00246-014-1014-3.
30.
CalamandreiMMirabileLMuschettaSGensiniGFDe SimoneLRomanoSM. Assessment of cardiac output in children: a comparison between the pressure recording analytical method and Doppler echocardiography. Pediatr Crit Care Med. 2008;9(3):310–312. doi:10.1097/PCC.0b013e31816c7151.
31.
RicciZPolitoANettoR. Assessment of modified ultrafiltration hemodynamic impact by pressure recording analytical method during pediatric cardiac surgery. Pediatr Crit Care Med. 2013;14(4):390–395. doi:10.1097/PCC.0b013e31828a7113.
32.
BettexDASchmidlinDBernathMA. Intraoperative transesophageal echocardiography in pediatric congenital cardiac surgery: a two-center observational study. Anesth Analg. 2003;97(5):1275–1282. doi:10.1213/01.ANE.0000081794.31004.18.
33.
ScohyTVGommersDMaatAPDejongPLBogersAJHoflandJ. Intraoperative transesophageal echocardiography is beneficial for hemodynamic stabilization during left ventricular assist device implantation in children. Paediatr Anaesth. 2009;19(4):390–395. doi:10.1111/j.1460-9592.2008.02917.x.
34.
LiJZhangGMc CrindleBW. Profiles of hemodynamics and oxygen transport derived by using continuous measured oxygen consumption after the Norwood procedure. J Thorac Cardiovasc Surg. 2007;133(2):441–448.
35.
IrazuztaJSullivanKJGarciaPCPivaJP. Pharmacologic support of infants and children in septic shock. J Pediatr (Rio J). 2007;83(2 Suppl): S36–S45. doi:10.2223/JPED.1623.
36.
Garcia GuerraGJoffeARSenthilselvanAKutsogiannisDJParshuramCS. Incidence of milrinone blood levels outside the therapeutic range and their relevance in children after cardiac surgery for congenital heart disease. Intensive Care Med. 2013;39(5):951–957. doi:10.1007/s00134-013-2858-3.
37.
MeyerSAbdul-KhaliqHGortnerL. The use of milrinone in pediatric intensive care medicine. Paediatr Anaesth. 2012;22(2):182–183. doi:10.1111/j.1460-9592.2011.03723.x.
38.
VogtW. Evaluation and optimisation of current milrinone prescribing for the treatment and prevention of low cardiac output syndrome in paediatric patients after open heart surgery using a physiology-based pharmacokinetic drug-disease model. Clin Pharmacokinet. 2014;53(1):51–72. doi:10.1007/s40262-013-0096-z.
39.
MomeniMRubayJMattaA. Levosimendan in congenital cardiac surgery: a randomized, double-blind clinical trial. J Cardiothorac Vasc Anesth. 2011;25(3):419–424. doi:10.1053/j.jvca.2010.07.004.
40.
LechnerEHoferALeitner-PenederG. Levosimendan versus milrinone in neonates and infants after corrective open-heart surgery: a pilot study. Pediatr Crit Care Med. 2012;13(5):542–548. doi:10.1097/PCC.0b013e3182455571.
41.
RicciZGaristoCFaviaIVitaleVDi ChiaraLCogoPE. Levosimendan infusion in newborns after corrective surgery for congenital heart disease: randomized controlled trial. Intensive Care Med. 2012;38(7):1198–1204. doi:10.1007/s00134-012-2564-6.
42.
TuranlahtiMBoldtTPalkamaTAntilaSLehtonenLPesonenE. Pharmacokinetics of levosimendan in pediatric patients evaluated for cardiac surgery. Pediatr Crit Care Med. 2004;5(5):457–462. doi:10.1097/01.PCC.0000137355.01277.9C.
43.
AngadiUWestropeCChowdhryMF. Is levosimendan effective in paediatric heart failure and post-cardiac surgeries?Interact Cardiovasc Thorac Surg. 2013;17(4):710–714. doi:10.1093/icvts/ivt29.
