Hostname: page-component-cd9895bd7-fscjk Total loading time: 0 Render date: 2024-12-28T14:54:10.226Z Has data issue: false hasContentIssue false
  • English
  • Français

A systematic review of the evidence supporting post-operative diuretic use following cardiopulmonary bypass in children with Congenital Heart Disease

Part of: Surgery

Published online by Cambridge University Press:  04 May 2021

Henry P. Foote ,
Christoph P. Hornik Open the ORCID record for Christoph P. Hornik [Opens in a new window] ,
Kevin D. Hill ,
Alexandre T. Rotta ,
Reid Chamberlain Open the ORCID record for Reid Chamberlain [Opens in a new window]  and
Elizabeth J. Thompson Open the ORCID record for Elizabeth J. Thompson [Opens in a new window]
Henry P. Foote
Affiliation:
Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
Christoph P. Hornik
Affiliation:
Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
Kevin D. Hill
Affiliation:
Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
Alexandre T. Rotta
Affiliation:
Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
Reid Chamberlain
Affiliation:
Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
Elizabeth J. Thompson*
Affiliation:
Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
*
Author for correspondence: Elizabeth J. Thompson, MD, Department of Pediatrics, Duke University School of Medicine, PO Box 17969, Durham, NC 27715, USA. Tel: 919-684-8111; Fax: 919-681-7892. E-mail: elizabeth.j.thompson@duke.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Background:

Paediatric cardiac surgery on cardiopulmonary bypass induces substantial physiologic changes that contribute to post-operative morbidity and mortality. Fluid overload and oedema are prevalent complications, routinely treated with diuretics. The optimal diuretic choice, timing of initiation, dose, and interval remain largely unknown.

Methods:

To guide clinical practice and future studies, we used PubMed and EMBASE to systematically review the existing literature of clinical trials involving diuretics following cardiac surgery from 2000 to 2020 in children aged 0–18 years. Studies were assessed by two reviewers to ensure that they met eligibility criteria.

Results:

We identified nine studies of 430 children across four medication classes. Five studies were retrospective, and four were prospective, two of which included randomisation. All were single centre. There were five primary endpoints – urine output, acute kidney injury, fluid balance, change in serum bicarbonate level, and required dose of diuretic. Included studies showed early post-operative diuretic resistance, suggesting higher initial doses. Two studies of ethacrynic acid showed increased urine output and lower diuretic requirement compared to furosemide. Children receiving peritoneal dialysis were less likely to develop fluid overload than those receiving furosemide. Chlorothiazide, acetazolamide, and tolvaptan demonstrated potential benefit as adjuncts to traditional diuretic regimens.

Conclusions:

Early diuretic resistance is seen in children following cardiopulmonary bypass. Ethacrynic acid appears superior to furosemide. Adjunct diuretic therapies may provide additional benefit. Study populations were heterogeneous and endpoints varied. Standardised, validated endpoints and pragmatic trial designs may allow investigators to determine the optimal diuretic, timing of initiation, dose, and interval to improve post-operative outcomes.

Keywords

Cardiopulmonary bypassCHDdiuretics
Type
Review
Information
Cardiology in the Young , Volume 31 , Issue 5 , May 2021 , pp. 699 - 706
Check for updates
Copyright
© The Author(s), 2021. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Liu, Y, Chen, S, Zuhlke, L, et al. Global birth prevalence of congenital heart defects 1970–2017: updated systematic review and meta-analysis of 260 studies. Int J Epidemiol 2019; 48: 455–463.10.1093/ije/dyz009CrossRefGoogle ScholarPubMed
Jacobs, JP, Mayer, JE Jr., Pasquali, SK, et al. The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2019 update on outcomes and quality. Ann Thorac Surg 2019; 107: 691–704.CrossRefGoogle Scholar
Jacobs, ML, O’Brien, SM, Jacobs, JP, et al. An empirically based tool for analyzing morbidity associated with operations for congenital heart disease. J Thorac Cardiovasc Surg 2013; 145: 1046–1057 e1.CrossRefGoogle ScholarPubMed
Kozik, DJ, Tweddell, JS Characterizing the inflammatory response to cardiopulmonary bypass in children. Ann Thorac Surg 2006; 81: S2347–S2354.10.1016/j.athoracsur.2006.02.073CrossRefGoogle ScholarPubMed
Nadim, MK, Forni, LG, Bihorac, A, et al. Cardiac and vascular surgery-associated acute kidney injury: the 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc 2018; 7: e008834.CrossRefGoogle ScholarPubMed
Seghaye, M-C, Grabitz, RG, Duchateau, J, et al. Inflammatory reaction and capillary leak syndrome related to cardiopulmonary bypass in neonates undergoing cardiac operations. J Thorac Cardiovasc Surg 1996; 112: 687–697.10.1016/S0022-5223(96)70053-3CrossRefGoogle ScholarPubMed
McCammond, AN, Axelrod, DM, Bailly, DK, Ramsey, EZ, Costello, JM Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: pharmacotherapies in cardiac critical care fluid management. Pediatr Crit Care Med 2016; 17: S35–S48.10.1097/PCC.0000000000000633CrossRefGoogle ScholarPubMed
Shi, S, Zhao, Z, Liu, X, et al. Perioperative risk factors for prolonged mechanical ventilation following cardiac surgery in neonates and young infants. Chest 2008; 134: 768–774.CrossRefGoogle ScholarPubMed
Hazle, MA, Gajarski, RJ, Yu, S, Donohue, J, Blatt, NB Fluid overload in infants following congenital heart surgery. Pediatr Crit Care Med 2013; 14: 44–49.10.1097/PCC.0b013e3182712799CrossRefGoogle ScholarPubMed
Hassinger, AB, Wald, EL, Goodman, DM Early postoperative fluid overload precedes acute kidney injury and is associated with higher morbidity in pediatric cardiac surgery patients. Pediatr Crit Care Med 2014; 15: 131–138.10.1097/PCC.0000000000000043CrossRefGoogle ScholarPubMed
Seguin, J, Albright, B, Vertullo, L, et al. Extent, risk factors, and outcome of fluid overload after pediatric heart surgery. Crit Care Med 2014; 42: 2591–2599.CrossRefGoogle ScholarPubMed
Lex, DJ, Toth, R, Czobor, NR, et al. Fluid overload is associated with higher mortality and morbidity in pediatric patients undergoing cardiac surgery. Pediatr Crit Care Med 2016; 17: 307–314.10.1097/PCC.0000000000000659CrossRefGoogle ScholarPubMed
Arikan, AA, Zappitelli, M, Goldstein, SL, Naipaul, A, Jefferson, LS, Loftis, LL Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med 2012; 13: 253–258.CrossRefGoogle ScholarPubMed
Vaara, ST, Korhonen, AM, Kaukonen, KM, et al. Fluid overload is associated with an increased risk for 90-day mortality in critically ill patients with renal replacement therapy: data from the prospective FINNAKI study. Crit Care 2012; 16: R197.10.1186/cc11682CrossRefGoogle ScholarPubMed
Torok, RD, Li, JS, Kannankeril, PJ, et al. Recommendations to enhance pediatric cardiovascular drug development: report of a multi-stakeholder think tank. J Am Heart Assoc 2018; 7: e007283.CrossRefGoogle ScholarPubMed
Zimmerman, K, Gonzalez, D, Swamy, GK, Cohen-Wolkowiez, M Pharmacologic studies in vulnerable populations: using the pediatric experience. Semin Perinatol 2015; 39: 532–536.CrossRefGoogle ScholarPubMed
King, CE, Thompson, EJ, Foote, HP, et al. An evidence-based review of the use of vasoactive and inotropic medications in post-operative paediatric patients after cardiac surgery with cardiopulmonary bypass from 2000 to 2020. Cardiol Young 2020: 30: 1757–1771.CrossRefGoogle ScholarPubMed
Borasino, S, Wall, KM, Crawford, JH, et al. Furosemide response predicts acute kidney injury after cardiac surgery in infants and neonates. Pediatr Crit Care Med 2018; 19: 310–317.10.1097/PCC.0000000000001478CrossRefGoogle ScholarPubMed
Lopez, C, Alcaraz, AJ, Toledo, B, Cortejoso, L, Gil-Ruiz, MA Acetazolamide therapy for metabolic alkalosis in pediatric intensive care patients. Pediatr Crit Care Med 2016; 17: e551–e558.10.1097/PCC.0000000000000971CrossRefGoogle ScholarPubMed
Haiberger, R, Favia, I, Romagnoli, S, Cogo, P, Ricci, Z Clinical factors associated with dose of loop diuretics after pediatric cardiac surgery: post hoc analysis. Pediatr Cardiol 2016; 37: 913–918.10.1007/s00246-016-1367-xCrossRefGoogle ScholarPubMed
Katayama, Y, Ozawa, T, Shiono, N, Masuhara, H, Fujii, T, Watanabe, Y Safety and effectiveness of tolvaptan for fluid management after pediatric cardiovascular surgery. Gen Thorac Cardiovasc Surg 2017; 65: 622–626.10.1007/s11748-017-0798-5CrossRefGoogle ScholarPubMed
Kerling, A, Toka, O, Rüffer, A, et al. First experience with Tolvaptan for the treatment of neonates and infants with capillary leak syndrome after cardiac surgery. BMC Pediatr 2019; 19: 57.CrossRefGoogle ScholarPubMed
Kwiatkowski, DM, Goldstein, SL, Cooper, DS, Nelson, DP, Morales, D, Krawczeski, CD Peritoneal dialysis vs furosemide for prevention of fluid overload in infants after cardiac surgery. JAMA Pediatr 2017; 171: 357–364.10.1001/jamapediatrics.2016.4538CrossRefGoogle ScholarPubMed
Ricci, Z, Haiberger, R, Pezzella, C, Garisto, C, Favia, I, Cogo, P Furosemide versus ethacrynic acid in pediatric patients undergoing cardiac surgery: a randomized controlled trial. Crit Care 2015; 19: 2.CrossRefGoogle ScholarPubMed
van der Vorst, MM, Ruys-Dudok van Heel, I, Kist-van Holthe, JE, et al. Continuous intravenous furosemide in haemodynamically unstable children after cardiac surgery. Intensive Care Med 2001; 27: 711–715.10.1007/s001340000819CrossRefGoogle ScholarPubMed
Carpenter, RJ, Kouyoumjian, S, Moromisato, DY, Lieu, P, Amirnovin, R Lower-dose, intravenous chlorothiazide is an effective adjunct diuretic to furosemide following pediatric cardiac surgery. J Pediatr Pharmacol Ther 2020; 25: 31–38.Google ScholarPubMed
Wittner, M, Di Stefano, A, Wangemann, P, Greger, R How do loop diuretics act? Drugs 1991; 41: 1–13.CrossRefGoogle ScholarPubMed
Brater, DC Pharmacodynamic considerations in the use of diuretics. Ann Rev Pharmacol Toxicol 1983; 23: 45–62.CrossRefGoogle ScholarPubMed
Brater, DC Clinical pharmacology of loop diuretics. Drugs 1991; 41: 14–22.CrossRefGoogle ScholarPubMed
Ikeda, K, Oshima, T, Hidaka, H, Takasaka, T Molecular and clinical implications of loop diuretic ototoxicity. Hear Res 1997; 107: 1–8.10.1016/S0378-5955(97)00009-9CrossRefGoogle ScholarPubMed
Ker, GL, Gangadharan, S Management of fluid overload in the pediatric ICU. Pediatric Critical Care 2019: 193–209.10.1007/978-3-319-96499-7_11CrossRefGoogle Scholar
Furosemide Injection, USP [package insert]. Shirley, NY: American Regent; 2011.Google Scholar
Ethacrynic Acid Tablets USP [package insert]. Parsippany, NJ: Edenbridge Pharmaceuticals; 2014.Google Scholar
Ellison, DH, Velazquez, H, Wright, FS Thiazide-sensitive sodium chloride cotransport in early distal tubule. Am J Physiol 1987; 253: F546–F54.Google ScholarPubMed
Ellison, DH The physiologic basis of diuretic synergism: its role in treating diuretic resistance. Ann Intern Med 1991; 114: 886–894.10.7326/0003-4819-114-10-886CrossRefGoogle ScholarPubMed
Jentzer, JC, DeWald, TA, Hernandez, AF Combination of loop diuretics with thiazide-type diuretics in heart failure. J Am Coll Cardiol 2010; 56: 1527–1534.CrossRefGoogle ScholarPubMed
Pasquali, SK, Hall, M, Slonim, AD, et al. Off-label use of cardiovascular medications in children hospitalized with congenital and acquired heart disease. Circ Cardiovasc Qual Outcomes 2008; 1: 74–83.10.1161/CIRCOUTCOMES.108.787176CrossRefGoogle ScholarPubMed
Moffett, BS, Tsang, R, Kennedy, C, Bronicki, RA, Akcan-Arikan, A, Checchia, PA Efficacy of sequential nephron blockade with intravenous chlorothiazide to promote diuresis in cardiac intensive care infants. Cardiol Young 2017; 27: 1104–1109.CrossRefGoogle ScholarPubMed
Wise, RT, Moffett, BS, Akcan-Arikan, A, Galati, M, Afonso, N, Checchia, PA Enhancement of diuresis with metolazone in infant paediatric cardiac intensive care patients. Cardiol Young 2018; 28: 27–31.CrossRefGoogle ScholarPubMed
Amin, HZ, Danny, SS Tolvaptan: A novel diuretic in heart failure management. J Teh Univ Heart Ctr 2015; 11: 1–5.Google Scholar
Konstam, MA, Gheorghiade, M, Burnett, JC, et al. Effects of oral tolvaptan in patients hospitalized for worsening heart failure. JAMA 2007; 297: 1319–1331.10.1001/jama.297.12.1319CrossRefGoogle ScholarPubMed
Higashi, K, Murakami, T, Ishikawa, Y, et al. Efficacy and safety of tolvaptan for pediatric patients with congestive heart failure. Multicenter survey in the working group of the Japanese Society of PEdiatric Circulation and Hemodynamics (J-SPECH). Int J Cardiol 2016; 205: 37–42.10.1016/j.ijcard.2015.12.003CrossRefGoogle Scholar
Wong, HR, Chundu, KR Metaboic alkalosis in children undergoing cardiac surgery. Crit Care Med 1993; 21: 884–887.CrossRefGoogle Scholar
Wilson, RF, Gibson, D, Percinel, AK, et al. Severe alkalosis in critically ill surgical patients. Arch Surg 1972; 105: 197–203.10.1001/archsurg.1972.04180080051009CrossRefGoogle ScholarPubMed
Anderson, LE, Henrich, WL Akalemia-associated morbidity and mortality in medical and surgical patients. South Med J 1987; 80: 729–733.CrossRefGoogle ScholarPubMed
Hanberg, JS, Rao, V, Ter Maaten, JM, et al. Hypochloremia and diuretic resistance in heart failure: mechanistic insights. Circ Heart Fail 2016; 9: 10.1161/CIRCHEARTFAILURE.116.003180 e003180.10.1161/CIRCHEARTFAILURE.116.003180CrossRefGoogle Scholar
Moviat, M, Pickkers, P, van der Voort, PH, van der Hoeven, JG Acetazolamide-mediated decrease in strong ion difference accounts for the correction of metabolic alkalosis in critically ill patients. Crit Care 2006; 10: R14.10.1186/cc3970CrossRefGoogle ScholarPubMed
Moffett, BS, Moffett, TI, Dickerson, HA Acetazolamide therapy for hypochlorimic metabolic alkalosis in pediatric patients with heart disease. Am J Therapeut 2007; 14: 331–335.10.1097/MJT.0b013e3180a72154CrossRefGoogle ScholarPubMed
Andrews, MG, Johnson, PN, Lammers, EM, Harrison, DL, Miller, JL Acetazolamide in critically ill neonates and children with metabolic alkalosis. Ann Pharmacother 2013; 47: 1130–1135.CrossRefGoogle ScholarPubMed
Singh, NC, Kissoon, N, Al Mofada, S, Bennett, M, Bohn, DJ Comparison of continuous versus intermittent furosemide administration in postoperative pediatric cardiac patients. Crit Care Med 1992; 20: 17–21.CrossRefGoogle ScholarPubMed
Klinge, JM, Scharf, J, Hofbeck, M, Gerling, S, Bonakdar, S, Singer, H Intermittent administration of furosemide versuse continuous infusion in the postoperaive managment of children following open heart surgery. Intensive Care Med 1997; 23: 693–697.10.1007/s001340050395CrossRefGoogle Scholar
Luciani, GB, Nichani, S, Chang, AC, Wells, WJ, Newth, CJ, Starnes, VA Continuous versus intermittent furosemide infusion in critically ill infants after open heart operations. Ann Thorac Surg 1997; 64: 1133–1139.CrossRefGoogle ScholarPubMed
Silversides, JA, Fitzgerald, E, Manickavasagam, US, et al. Deresuscitation of patients with iatrogenic fluid overload is associated with reduced mortality in critical illness. Crit Care Med 2018; 46: 1600–1607.10.1097/CCM.0000000000003276CrossRefGoogle ScholarPubMed
van Saet, A, de Wildt, SN, Knibbe, CA, Bogers, AD, Stolker, RJ, Tibboel, D The effect of adult and pediatric cardiopulmonary bypass on pharmacokinetic and pharmacodynamic parameters. Curr Clin Pharmacol 2013; 8: 297–318.10.2174/15748847113089990067CrossRefGoogle ScholarPubMed
Bailey, JM, Miller, BE, Lu, W, Tosone, SR, Kanter, K, Tam, VK The pharmacokinetics of milrinone in pediatric patients after cardiac surgery. Anesthesiology 1999; 90: 1012–1018.10.1097/00000542-199904000-00014CrossRefGoogle ScholarPubMed
Hill, KD, Baldwin, HS, Bichel, DP, et al. Rationale and design of the STeroids to REduce Systemic inflammation after infant heart Surgery (STRESS) trial. Am Heart J 2020; 220: 192–202.CrossRefGoogle ScholarPubMed
Woodcock, J, LaVange, LM Master protocols to study multiple therapies, multiple diseases, or both. N Engl J Med 2017; 377: 62–70.CrossRefGoogle ScholarPubMed