Prognostic Value of a New Lung Ultrasound Score to Predict Intensive Care Unit Stay in Pediatric Cardiac Surgery

doi:10.1016/j.athoracsur.2019.06.057

The Annals of Thoracic Surgery

Volume 109, Issue 1, January 2020, Pages 178-184

https://doi.org/10.1016/j.athoracsur.2019.06.057 Get rights and content

Background

Lung ultrasound (LUS) in pediatric cardiac surgery is gaining consensus. We (1) evaluated the prognostic value of a new LUS-score in pediatric cardiac surgery, and (2) compared LUS-score to conventional risk factors including age, The Society of Thoracic Surgeons/European Association of Cardio-Thoracic Surgery (STAT) score, cardiopulmonary bypass time, and prognostic biomarkers including brain natriuretic peptide and cystatin-C.

Methods

LUS examinations were performed in 237 children (median age, 0.55 years; interquartile range, 0.09-4.15 years) at 12 to 36 hours after surgery. For each hemithorax, 3 areas (anterior/lateral/posterior) were evaluated in the upper and lower halves, constituting 12 total scanning areas. For each site a score was assigned: 0 (rare B lines), 1 (separated B lines), 2 (coalescent B lines), 3 (loss of aeration), and total LUS score was calculated as sum of all sites. The primary endpoints were intensive care unit length of stay and extubation time.

Results

The mean total LUS score was 12.88 ± 6.41 (range, 0-26) and was higher in newborns (16.77 ± 5.25) compared with older children (5.36 ± 5.57; P < .001). On univariate analysis, LUS score was associated inversely with age (beta 0.26; P = .004) and body surface area (beta 3.41 P = .006) and positively with brain natriuretic peptide (beta 1.65; P < .001) and cystatin-C (beta 2.41; P < .001). The LUS score, when added as continuous predictor to a conventional risk model (age, STAT score, and cardiopulmonary bypass time) emerged significant both for intensive care unit length of stay (beta 0.145, P = .047) and extubation time (beta 1.644; P = .024). When single quadrants were analyzed, only anterior LUS score was significant (intensive care unit length of stay beta, 0.471; P = .020; extubation time beta 5.530; P = .007).

Conclusions

Our data show the prognostic incremental value of a new LUS score over traditional risk factors in pediatric cardiac surgery.

Section snippets

Study Protocol

All children and adolescents (<18 years old) undergoing corrective or palliative CHD surgery between June 2015 and May 2018 at the Department of Pediatric Cardiac Surgery of Fondazione CNR–Regione Toscana G. Monasterio were prospectively enrolled. Children previously palliated (shunts, pulmonary artery banding, Norwood stage 1 procedure, cavopulmonary palliation) were included, and patients who had a previous correction (redo surgery) were also included. Only patients with adequate acoustic

Population

In 392 prospectively enrolled patients, 1172 LUS examinations were performed at different postoperative intervals. Of these we selected exams performed at 12-36 hours after surgery. These corresponded to the time of first complete postoperative evaluation and yielded a total of 248 LUS examinations for final analysis. Of these, 5 examinations were exclude because of poor acoustic window and 6 because of incomplete examination (including 6 neonates with open sternotomy after surgery), leaving

Comment

Our data provide the prognostic value of LUS examinations from a large cohort of infants and children undergoing surgery for CHD. Although the diagnostic accuracy of LUS in the diagnosis of pulmonary complications in the pediatric setting4, 7—including cardiac surgery—is well established, data on the prognostic power of LUS are limited.7, 14 Furthermore, comparison with other established outcome markers have never been tested. Notably, the new LUS score reported here was compared to traditional

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Point-of-Care-Ultrasound in Pediatrics: A Review and Update
2024, Seminars in Ultrasound, CT and MRI
Point-of-Care-Ultrasound (POCUS) has encountered a tremendous expansion in patient care. POCUS has taken a central role during invasive procedures. POCUS has expanded to most subspecialties from adult to pediatric and neonatal health care. POCUS in pediatrics has also become part of specific critical situations such as myocardial function assessment during cardiac arrest, extracorporeal membrane oxygenation deployment and neurological evaluation. In this review we will go over the most important historical aspects of POCUS. We will also review important aspects of POCUS in the intensive care unit, cardiologist evaluation and in the emergency department among others.
Optimization of lung ultrasound in ultrafast-track anesthesia for non-cyanotic congenital heart disease surgery
2024, Heliyon
We aimed to explore the feasibility of lung ultrasound for perioperative assessment and the optimal effect of lung ultrasound in reducing lung complications during non-cyanotic congenital heart disease (CHD) surgery using ultrafast-track anesthesia.
Sixty patients were treated at Shenzhen Children's Hospital between 2019 and 2020. Of these, 30 patients in group N had an indication for extubation and ultrafast-track anesthesia after congenital heart surgery; the tracheal catheter was removed, and the patients were sent to the cardiac intensive care unit (CICU) for further monitoring and treatment. Another 30 patients were in group L and also had an indication for extubation and ultrafast-track anesthesia; in addition we compared lung ultrasound score (LUS) before and after surgery, when we found the cases that LUS ≥ 15, for whom targeted optimization treatment would be carried out. The tracheal catheter was removed after LUS <15 days before the patients were sent to the CICU. In all cases, the LUS and PaO2/FiO2 ratios (P/F) of both groups were recorded at the time of anesthesia induction (T₀), before extubation (T₁), and 5 min (T₂), 1 h (T₃), and 24 h (T₄) after extubation. The incidence of pulmonary complications, LUS, and P/F were compared between the two groups.
There was great consistency between LUS and radiographic findings. Comparing the data of the two groups at T₂, T₃ and T₄, the P/F was higher and the LUS was lower in group L than in group N. The incidence of lung complications in group L (18 cases, 60 %) was lower than that in group N (26 cases, 86.7 %, χ2 = 5.46, P = 0.02); comparing LUS between T₀ and T₃, LUS decreased in a greater number of cases in group L (15, 50 %) than in group N (7 cases, 23.3 %, χ2 = 4.59, P = 0.032).
Lung ultrasonography can effectively help assess lung conditions. Optimization guided by lung ultrasound in ultrafast track anesthesia can significantly reduce postoperative lung complications.
Utility of Lung Ultrasound in the Estimation of Extravascular Lung Water in a Pediatric Population—A Prospective Observational Study
2022, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Hence, external validation and further exploration of the results in larger multicenter cohorts should be done. Multiple scoring systems for LUS, including automated analysis, have been described.9,11,14,16,31,34 The various scoring systems need to be compared among themselves and standardized.
Lung ultrasound (LUS) is a promising bedside modality for the estimation of extravascular lung water index (EVLWI), but has not been validated against objective measures in children. This study aimed to investigate the correlation of LUS B-line scoring with EVLWI, thresholds indicating elevated EVLWI, and its outcome following pediatric cardiac surgery.
Prospective observational study.
Cardiothoracic surgical intensive care unit in a tertiary care teaching hospital.
Children younger than 12 years undergoing elective complete surgical correction of cyanotic or acyanotic congenital heart disease (Aristotle score ≤9), excluding neonates, those weighing <3.5 kg, and those with thoracic deformities, pulmonary pathology, and hemodynamic instability.
Extravascular lung water index measurement by transpulmonary thermodilution, along with concurrent LUS B-line and Chest-X ray (CXR) scoring.
LUS B-line score had a moderate correlation with EVLWI (Pearson’s correlation coefficient 0.57; 95% CI 0.44-0.69). LUS B-line scores showed acceptable discrimination only for higher thresholds of EVLWI (sensitivity 82% and 79%, respectively, for EVLWI >20 mL/kg v sensitivity and specificity 57% and 80% for EVLWI >10 mL/kg). Age, body surface area, vasoactive-inotropic score (VIS), chest X-ray score, and EVLWI but not LUS B-line score were significant predictors for duration of mechanical ventilation in this cohort.
LUS B-line scoring has limited utility in semiquantitative estimation of EVLWI at lower thresholds of EVLWI in pediatric cardiac surgical patients. It may have better discrimination and acceptable sensitivity and specificity at higher thresholds of EVLWI. Contrasting with multiple reports of clinical utility, these results call for wider evaluation of LUS and its clinical modifiers like age, pathology, and pretest probability in estimation of EVLWI.
Usefulness of lung ultrasound in the diagnosis and follow-up of respiratory diseases in neonates
2022, Anales de Pediatria
La ecografía pulmonar es una herramienta útil para el diagnóstico y seguimiento de la patología del paciente crítico neonatal. Su uso está cada vez más extendido gracias a sus ventajas sobre otras pruebas de imagen y el rápido incremento en la evidencia científica a su favor, constituyendo así, un pilar básico de las guías «point of care ultrasound» (POCUS) neonatal. El objetivo de este artículo especial es proporcionar las bases y aplicaciones diagnóstico-terapéuticas establecidas de la ecografía pulmonar, y dar a conocer nuevas aplicaciones.
La sección de ecografía pulmonar del Grupo de Trabajo de Ecografía Neonatal de la Sociedad Española de Neonatología resume la evidencia científica actual. Se describen los patrones ecográficos de las principales patologías respiratorias, aborda algunas de sus aplicaciones en la asistencia neonatal (predicción de ingreso, necesidad de surfactante, procedimientos ecoguiados, seguimiento del desarrollo pulmonar en el prematuro, entre otros) y propone su incorporación en otros escenarios actualmente menos establecidos como la reanimación o el manejo ventilatorio.
Este artículo reafirma los beneficios de esta herramienta para ayudar en el diagnóstico, toma de decisiones terapéuticas, apoyo en procedimientos y valoración pronóstica.
La ecografía pulmonar debe establecerse como la prueba diagnóstica de elección en la patología respiratoria neonatal. Por ello, su entrenamiento debería formar parte de la formación de los neonatólogos e incluirse en los protocolos diagnóstico-terapéuticos asistenciales. Se deben seguir desarrollando líneas de investigación con estudios sólidos y multicéntricos que aumenten la calidad de la evidencia científica.
Lung ultrasound is a useful tool for diagnosis and follow-up of diseases in critically ill neonates. Its use is increasingly widespread thanks to its advantages over other imaging tests and the rapidly growing body of evidence to support it, and «point-of-care ultrasound» (POCUS) has become a key component in neonatal guidelines. The objective of this special article is to present the foundations and the established diagnostic and therapeutic applications of lung ultrasonography as well as introducing new applications.
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Coronavirus Disease 2019 Phenotypes, Lung Ultrasound, Chest Computed Tomography and Clinical Features in Critically Ill Mechanically Ventilated Patients
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Citation Excerpt :
We followed a 12-zone protocol (Mento et al. 2020). Each intercostal space of upper and lower parts of the anterior, lateral and posterior regions of the left and right chest wall were carefully examined, and findings (pleural effusion, confluent and isolated B-lines, irregular pleural line, consolidations) were recorded on 10 s video clips (Cantinotti et al. 2020; Perrone et al., 2021; Volpicelli and Gargani, 2020a; Volpicela, 2020b). For each of the 12 zones, a score from 0–3 was given according to the finding: irregular or isolated B-lines (1 point), confluent B-lines (2 points) and consolidations or pleural effusion (3 points).
Chest computed tomography (CT) may provide insights into the pathophysiology of coronavirus disease 2019 (COVID-19), although it is not suitable for a timely bedside dynamic assessment of patients admitted to intensive care unit (ICU); therefore, lung ultrasound (LUS) has been proposed as a complementary diagnostic tool. The aims of this study were to investigate different lungs phenotypes in patients with COVID-19 and to assess the differences in CT and LUS scores between ICU survivors and non-survivors. We also explored the association between CT and LUS, and oxygenation (arterial partial pressure of oxygen [PaO₂]/fraction of inspired oxygen [FiO_2]) and clinical parameters. The study included 39 patients with COVID-19. CT scans revealed types 1, 2 and 3 phenotypes in 62%, 28% and 10% of patients, respectively. Among survivors, pattern 1 was prevalent (p < 0.005). Chest CT and LUS scores differed between survivors and non-survivors both at ICU admission and 10 days after and were associated with ICU mortality. Chest CT score was positively correlated with LUS findings at ICU admission (r = 0.953, p < 0.0001) and was inversely correlated with PaO₂/FiO₂ (r = –0.375, p = 0.019) and C-reactive protein (r = 0.329, p = 0.041). LUS score was inversely correlated with PaO₂/FiO₂ (r = –0.345, p = 0.031). COVID-19 presents distinct phenotypes with differences between survivors and non-survivors. LUS is a valuable monitoring tool in an ICU setting because it may correlate with CT findings and mortality, although it cannot predict oxygenation changes.
Lung Injury After Neonatal Congenital Cardiac Surgery Is Mild and Modifiable by Corticosteroids
2021, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Previously, the CXR LE score was used successfully to detect lung injury after the unifocalization procedure in tetralogy of Fallot patients with pulmonary atresia and major aortopulmonary collateral arteries.14 Clinically, CXRs are used, although lung ultrasound has shown some potential in measurement of lung edema and prognosis of intensive care unit stay length after congenital cardiac surgery.18,19 The improvement in dynamic Crs during the first PODs in the patients who received the SDC regimen was in line with previous studies on adults and animals, whereas a previous pediatric study failed to demonstrate an effect of postoperative inhaled corticosteroids on dynamic Crs.11,20,21
The present study was performed to determine whether lung injury manifests as lung edema in neonates after congenital cardiac surgery and whether a stress-dose corticosteroid (SDC) regimen attenuates postoperative lung injury in neonates after congenital cardiac surgery.
A supplementary report of a randomized, double-blinded, placebo-controlled clinical trial.
A pediatric tertiary university hospital.
Forty neonates (age ≤28 days) undergoing congenital cardiac surgery with cardiopulmonary bypass.
After anesthesia induction, patients were assigned randomly to receive intravenously either 2 mg/kg methylprednisolone or placebo b, which was followed by hydrocortisone or placebo bolus six hours after weaning from CPB for five days as follows: 0.2 mg/kg/h for 48 hours, 0.1 mg/kg/h for the next 48 hours, and 0.05 mg/kg/h for the following 24 hours.
The chest radiography lung edema score was lower in the SDC than in the placebo group on the first postoperative day (POD one) (p = 0.03) and on PODs two and three (p = 0.03). Furthermore, a modest increase in the edema score of 0.9 was noted in the placebo group, whereas the edema score remained at the preoperative level in the SDC group. Postoperative dynamic respiratory system compliance was higher in the SDC group until POD three (p < 0.01). However, postoperative oxygenation; length of mechanical ventilation; and tracheal aspirate biomarkers of inflammation and oxidative stress, namely interleukin-6, interleukin-8, resistin, and 8-isoprostane, showed no differences between the groups.
The SDC regimen reduced the development of mild and likely clinically insignificant radiographic lung edema and improved postoperative dynamic respiratory system compliance without adverse events, but it failed to improve postoperative oxygenation and length of mechanical ventilation.

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Original articleCongenital heart surgeryPrognostic Value of a New Lung Ultrasound Score to Predict Intensive Care Unit Stay in Pediatric Cardiac Surgery

Background

Methods

Results

Conclusions

Section snippets

Study Protocol

Population

Comment

Early Hum Dev

J Thorac Cardiovasc Surg

Clin Chim Acta

Ann Thorac Surg

Ann Thorac Surg

International evidence-based recommendations for point-of-care lung ultrasound

Intensive Care Med

Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis

Pediatrics

Original article
Congenital heart surgery
Prognostic Value of a New Lung Ultrasound Score to Predict Intensive Care Unit Stay in Pediatric Cardiac Surgery