Enrique G. Villarreal

University of Toronto

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Saúl Flores

Texas Children's Hospital

Rohit S. Loomba

University of California, San Diego

Juan S. Farias

Children's Mercy Hospital

Ronald A. Bronicki

Baylor College of Medicine

Jacqueline Rausa

Cohen Children's Medical Center

Fabio Savorgnan

Texas Children's Hospital

Vincent Dorsey

Advocate Children's Hospital

Riddhi Patel

Advocate Children's Hospital

Sebastián Acosta

Texas Children's Hospital

Joshua Wong

Rosalind Franklin University of Medicine and Science

Cooperative Institutions

Advocate Children's Hospital

Tecnológico de Monterrey

Texas Children's Hospital

Baylor College of Medicine

Rosalind Franklin University of Medicine and Science

Secretaria de Salud

Hospital Christus Muguerza Alta Especialidad

University of Chicago

Cincinnati Children's Hospital Medical Center

Children's Mercy Hospital

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Correlation of hepatic venous saturation and mixed venous saturation: pooled analyses

Minerva Pediatrics (2023)

Rohit S. Loomba Juan S. Farias Enrique G. Villarreal Saúl Flores

INTRODUCTION: In critical care, monitoring adequate tissue oxygenation is essential. Mixed venous oxygen saturation has traditionally been considered the gold standard for measuring cardiac output, which represents systemic oxygen delivery. Studies have shown that hepatic vein saturation is correlated with mixed venous oxygen saturation and mortality. The primary aim of this study was to determine the correlation between hepatic vein saturation and mixed venous saturation, and the impact of clinical characteristics on this correlation.EVIDENCE ACQUISITION: A systematic review of the literature was performed to identify manuscripts. They must have included patients who received simultaneous mixed venous saturations and hepatic vein saturations, and the data for both must have been explicitly shared. Data were pooled from these studies to analyze the correlation between mixed venous saturation and the corresponding hepatic vein saturation.EVIDENCE SYNTHESIS: A total of 13 studies with 333 patients were included in the final analyses. The average age across these studies was 60.3±5.2. The pooled correlation between the mixed venous saturation and hepatic vein saturation was 0.88, demonstrating a strong correlation between the two. The average mixed venous saturation was 73.3±5.0 while the average hepatic vein saturation was 59.5±11.1.CONCLUSIONS: In these pooled analyses, hepatic vein saturation has a strong correlation with mixed venous saturation. This correlation is not significantly impacted by patient age, weight, or clinical setting. Nonetheless, further prospective studies are needed for confirmation.

Saturation (graph theory)

Oxygen Saturation

10.23736/s2724-5276.23.07208-7

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Comorbidities, pharmacologic interventions, and mechanical interventions associated with mortality in isolated diastolic left heart failure: lessons from a national database and a clinical simulator

Research Square (Research Square) (2022)

Rohit S. Loomba Nobuyuki Ikeda Juan S. Farias Enrique G. Villarreal Saúl Flores

Abstract Background : Diastolic heart failure may be noted in pediatric patients with congenital heart disease, cardiomyopathy, or malignancies requiring chemotherapy, but the available data are scarce, and often derived from adult trials or based on theoretic or anecdotal evidence. Methods: Data between 2016 and 2021 were obtained from Pediatric Health Information System database. Patients < 18 years of age with isolated diastolic heart failure admitted to intensive care unit at some point during admission were included. They were divided into patients with and without inpatient mortality. Patients’ demographics, comorbidities using ICD-10 codes, and pharmacologic interventions were also recorded. Univariate analysis was done in demographics, comorbidities, pharmacologic interventions, and mechanical interventions between admissions with and without mortality. Multivariable logistic regression was done for inpatient mortality and multivariable linear regression was done for total hospital length of stay in survivors. Results: Isolated diastolic heart failure comprised 0.5% of critically ill pediatric patients. 121 (5%) experienced mortality among the 2,273 admissions in the final analyses. Milrinone and angiotensin converting enzyme inhibitor were found to be associated with decreased mortality. Increasing age and diuretics were associated with decreased total hospital length of stay in survivors. Conclusion: Pediatric critical care admissions with isolated diastolic left heart failure have a 5% mortality. Several comorbidities and interventions are associated with increased mortality with milrinone and angiotensin converting enzyme inhibitors being associated with decreased risk of mortality. When only admissions with survival to discharge are considered, older age and diuretics are associated with lower total hospital length of stay.

Milrinone

10.21203/rs.3.rs-2155834/v1

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C‐reactive protein and procalcitonin after congenital heart surgery utilizing cardiopulmonary bypass: When should we be worried?

Journal of Cardiac Surgery (2021)

Juan S. Farias Enrique G. Villarreal Janhavi Dhargalkar Alicia Kleinhans Saúl Flores

Introduction To assess the efficacy of C-reactive protein (CRP) and procalcitonin (PCT) at identifying infection in children after congenital heart surgery (CHS) with cardiopulmonary bypass (CPB). Materials and Methods Systematic review of the literature was conducted to identify studies with data regarding CRP and/or PCT after CHS with CPB. The primary variables identified to be characterized were CRP and PCT at different timepoints. The main inclusion criteria were children who underwent CHS with CPB. Subset analyses for those with and without documented infection were conducted in similar fashion. A p value of less than .05 was considered statistically significant. Results A total of 21 studies were included for CRP with 1655 patients and a total of 9 studies were included for PCT with 882 patients. CRP peaked on postoperative Day 2. A significant difference was noted in those with infection only on postoperative Day 4 with a level of 53.60 mg/L in those with documented infection versus 29.68 mg/L in those without. PCT peaked on postoperative Day 2. A significant difference was noted in those with infection on postoperative Days 1, 2, and 3 with a level of 12.9 ng/ml in those with documented infection versus 5.6 ng/ml in those without. Conclusions Both CRP and PCT increase after CHS with CPB and peak on postoperative day 2. PCT has a greater statistically significant difference in those with documented infection when compared to CRP and a PCT of greater than 5.6 ng/ml should raise suspicion for infection.

Procalcitonin

10.1111/jocs.15952

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Randomized Controlled Trials in Pediatric Cardiology: A Power Struggle?

Pediatric Cardiology (2022)

Francisco Eugenio Herrera-Carrillo Riddhi Patel Saúl Flores Enrique G. Villarreal Juan S. Farias

Clinical endpoint

Vascular surgery

Statistical power

10.1007/s00246-022-03039-z

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Factors associated with deep venous thrombosis in patients infected with coronavirus disease 2019: a meta-analysis

Blood Coagulation & Fibrinolysis (2020)

Rohit S. Loomba Gaurav Aggarwal Enrique G. Villarreal Juan S. Farias Saúl Flores

Coronavirus disease 2019 (COVID-19) has affected more than 6 million patients worldwide. Deep venous thrombosis (DVT) has been increasingly recognized complication in these patients and is associated with increased morbidity and mortality. However, the factors associated with development of DVT in patients with COVID-19 have not been elucidated due to the novelty of the virus. We performed a meta-analysis of published studies comparing laboratory results in COVID-19 patients with and without DVT with the aim of identifying risk factors. We searched major databases for studies evaluating DVT in COVID-positive patients and performed a meta-analysis of baseline laboratory markers associated with development of DVT. A total of six studies with 678 patients were included in the pooled analyses. Of the 678 patients, 205 of patients had a DVT. Patients diagnosed with DVT were more likely to be older [mean difference 4.59 years, 95% confidence interval (CI) 1.25-7.92], and needing admission to ICU (relative risk 1.96, 95% CI 1.09-3.51). Patients with DVT had significantly higher white cell count (mean difference 1.36 × 109/l, 95% CI 0.33-2.40) and d-dimer levels (mean difference 3229.8, 95% CI 1501.5-4958.1). Lymphocyte count was lower in patients with DVT (mean difference -0.19 × 109/l, 95% CI -0.37 to -0.02). Patients with COVID-19 who develop DVT are more likely to be older and have leukocytosis with lymphopenia. Moreover, d-dimer is statistically higher and patients that are admitted to the ICU are at great risk to develop DVT.

Leukocytosis

10.1097/mbc.0000000000000974

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Peritoneal dialysis during congenital heart surgery admissions: insights from a large database

Cardiology in the Young (2020)

Rohit S. Loomba Enrique G. Villarreal Ronald A. Bronicki Saúl Flores

Abstract Background: The management of fluid overload after congenital heart surgery has been limited to diuretics, fluid restriction, and dialysis. This study was conducted to determine the association between peritoneal dialysis and important clinical outcomes in children undergoing congenital heart surgery. Methods: A retrospective review was conducted to identify patients under 18 years of age who underwent congenital heart surgery. The data were obtained over a 16-year period (1997–2012) from the Kids’ Inpatient Database. Data analysed consisted of demographics, diagnoses, type of congenital heart surgery, length of stay, cost of hospitalisation, and mortality. Logistic regression was performed to determine factors associated with peritoneal dialysis. Results: A total of 46,176 admissions after congenital heart surgery were included in the study. Of those, 181 (0.4%) utilised peritoneal dialysis. The mean age of the peritoneal dialysis group was 7.6 months compared to 39.6 months in those without peritoneal dialysis. The most common CHDs were atrial septal defect (37%), ventricular septal defect (32.6%), and hypoplastic left heart syndrome (18.8%). Univariate analyses demonstrated significantly greater length of stay, cost of admission, and mortality in those with peritoneal dialysis. Regression analyses demonstrated that peritoneal dialysis was independently associated with significant decrease in cost of admission (−$57,500) and significant increase in mortality (odds ratio 1.5). Conclusions: Peritoneal dialysis appears to be used in specific patient subsets and is independently associated with decreased cost of stay, although it is associated with increased mortality. Further studies are needed to describe risks and benefit of peritoneal dialysis in this population.

Univariate analysis

10.1017/s1047951120000141

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Association between neutrophil-lymphocyte-ratio and oxygen delivery in patients after the Norwood operation

Research Square (Research Square) (2023)

Rohit S. Loomba Juan S. Farias Enrique G. Villarreal Saúl Flores

Abstract Background Both neutrophil-lymphocyte-ratio and renal oxygen extraction have been demonstrated to be associated with adverse events after cardiac surgery. The association between neutrophil-lymphocyte-ratio and renal oxygen extraction has not previously been studies. The aim of this study was to characterize the association between neutrophil-lymphocyte ratio and renal oxygen extraction. Methods High fidelity hemodynamic monitoring data was retrieved for patients who underwent the Norwood operation. Bayesian regression analyses were conducted to identify what hemodynamic variables, including renal oxygen extraction, were associated with neutrophil-lymphocyte ratio. Results A total of 27,270 datapoints were collected over 1,338 patient-hours for nine unique patients. Renal oxygen extraction ratio had an area under the curve of 0.72 to identify renal oxygen extraction of over 35%. An increase in renal oxygen extraction by 1 was associated with a 0.15 increase in the neutrophil-lymphocyte-ratio. Conclusion In patients after the Norwood procedure, there is a correlation between the neutrophil-lymphocyte-ratio and renal oxygen extraction. A neutrophil-lymphocyte-ratio of greater than 2.95 has fair-performance in identifying renal extraction of greater than 35%.

Extraction ratio

10.21203/rs.3.rs-3343398/v1

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Serum Lactate and Mortality during Pediatric Admissions: Is 2 Really the Magic Number?

Journal of Pediatric Intensive Care (2022)

Rohit S. Loomba Juan S. Farias Enrique G. Villarreal Saúl Flores

Abstract The primary objective of this study was to determine if serum lactate level at the time of hospital admission can predict mortality in pediatric patients. A systematic review was conducted to identify studies that assessed the utility of serum lactate at the time of admission to predict mortality in pediatric patients. The areas under the curve from the receiver operator curve analyses were utilized to determine the pooled area under the curve. Additionally, standardized mean difference was compared between those who survived to discharge and those who did not. A total of 12 studies with 2,099 patients were included. Out of these, 357 (17%) experienced mortality. The pooled area under the curve for all patients was 0.74 (0.67–0.80, p < 0.01). The pooled analyses for all admissions were higher in those who experienced mortality (6.5 vs. 3.3 mmol/L) with a standardized mean difference of 2.60 (1.74–3.51, p < 0.01). The pooled area under the curve for cardiac surgery patients was 0.63 (0.53–0.72, p < 0.01). The levels for cardiac surgery patients were higher in those who experienced mortality (5.5 vs. 4.1 mmol/L) with a standardized mean difference of 1.80 (0.05–3.56, p = 0.04). Serum lactate at the time of admission can be valuable in identifying pediatric patients at greater risk for inpatient mortality. This remained the case when only cardiac surgery patients were included.

Magic number (chemistry)

10.1055/s-0042-1743180

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Extracorporeal Cardiopulmonary Resuscitation in Acute Fulminant Myocarditis: A Case Report and Review of the Literature

Journal of Pediatric Intensive Care (2020)

Jesus Andres Rodriguez-Coronado Jesus Arturo Saldivar-Martinez René Gómez-Gutiérrez Guillermo Quezada-Valenzuela Maria Veronica Contreras-Cepeda

Fulminant myocarditis is a life-threatening fast progressive condition. We present a 7-year-old female patient admitted with a diagnosis of acute myocarditis with a rapidly progressive cardiac dysfunction despite conventional vasoactive and inotropic treatment. The patient presented with ventricular fibrillation and subsequent cardiac arrest. Cardiopulmonary resuscitation (CPR) was performed during 105 minutes before extracorporeal membrane oxygenation (ECMO) cannulation was performed. Effective hemodynamic function was obtained, and ECMO was weaned after 7 days, without neurological complications. There are not established extracorporeal cardiopulmonary resuscitation (eCPR) treatment criteria, and some international guidelines consider up to 100 minutes of "low flow" phase as a time limit to start the support. Some mortality risk factors for ECMO treatment mortality are female gender, renal failure, and arrhythmias. Pre-ECMO good prognostic factors are high levels of pH and blood lactate.

Extracorporeal cardiopulmonary resuscitation

Fulminant

Extracorporeal

10.1055/s-0040-1709499

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P0235 / #981: EXTRACORPOREAL MEMBRANE OXYGENATION AS A TREATMENT FOR REFRACTORY LACTIC ACIDOSIS DUE TO GLYCOGEN STORAGE DISEASE TYPE 1A: A CASE REPORT

Pediatric Critical Care Medicine (2021)

J. Rodriguez Coronado J. Saldivar Martinez René Gómez-Gutiérrez G. Quezada Valenzuela Marcos Cepeda

Aims & Objectives: Glycogen storage disease (GSD) type Ia (Von Gierke's Disease) is an infrequent metabolic disease characterized by the deficient activity of glucose-6-phosphate-a. This deficiency causes the accumulation of glycogen in the body leading to hypoglycemia, lactic acidosis, failure to thrive, hepatomegaly, hepatic adenomas, renal failure and inflammatory bowel disease. The aim of this study is to describe a case of GSD type Ia and to evaluate the utility of Extracorporeal Membrane Oxygenation (ECMO) to treat this condition. Methods: We present a 7-year-old male patient with a history of GSD type 1a. The patient arrived at the hospital due to diarrhea and emesis. Patient is treated with intravenous fluids and glucose infusion, however, clinical stabilization is not met after 24-hours. Patient develops hemodynamic instability secondary to lactic and metabolic acidosis and is transferred to the pediatric intensive care unit (PICU). At the fifth day of admission at the PICU hemodynamic and respiratory status worsens. Results: Mechanical ventilation and vasopressor therapy are initiated. Patient is placed into hemodialysis (PRISMA FLEX®) to treat refractory lactic acidosis, fluid overload, and acute kidney injury. 48-hours later the PICU team emergently cannulated for veno-arterial (VA) ECMO support. During the following days patient's hemodynamic and metabolic status improves. Patient ECMO support was stopped 7 days after initiation. PRISMAFLEX® management continued for 9 days until renal function normalized. Patient was discharged 58 days after hospital admission with no neurological complications. Conclusions: This case emphasizes the efficacy of ECMO as a therapy to stabilize pediatric patients with metabolic diseases such as GSD Type 1a

Lactic acidosis

Renal replacement therapy

Hemofiltration

10.1097/01.pcc.0000739284.30693.b5

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Citations (1)