Review
Protecting the Infant Brain During Cardiac Surgery: A Systematic Review

Presented at the Forty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–Feb 1, 2012.
https://doi.org/10.1016/j.athoracsur.2012.05.135Get rights and content

Prevention of brain injury during congenital heart surgery has focused on intraoperative and perioperative neuroprotection and neuromonitoring. Many strategies have been adopted as “standard of care.” However, the strength of evidence for these practices and the relationship to long-term outcomes are unknown.

We performed a systematic review (January 1, 1990 to July 30, 2010) of neuromonitoring and neuroprotection strategies during cardiopulmonary bypass (CPB) in infants of age 1 year or less. Papers were graded individually and as thematic groups, assigning evidence-based medicine and American College of Cardiology/American Heart Association (ACC/AHA) level of evidence grades. Consensus scores were determined by adjudication.

Literature search identified 527 manuscripts; 162 met inclusion criteria. Study designs were prospective observational cohort (53.7%), case-control (21.6%), randomized clinical trial (13%), and retrospective observational cohort (9.9%). Median sample size was 43 (range 3 to 2,481). Primary outcome was evidence of structural brain injury or functional disability (neuroimaging, electroencephalogram, formal neurologic examination, or neurodevelopmental testing) in 43%. Follow-up information was reported in only 29%. The most frequent level of evidence was evidence-based medicine level 4 (33.3%) or ACC/AHA class IIB: level B (42%). The only intervention with sufficient evidence to recommend “the procedure or treatment should be performed” was avoidance of extreme hemodilution during CPB.

Data supporting use of current neuromonitoring and neuroprotective techniques are limited. The level of evidence is insufficient to support effectiveness of most of these strategies. Well-designed studies with correlation to clinical outcomes and long-term follow-up are needed to develop guidelines for neuromonitoring and neuroprotection during CPB in infants.

Section snippets

Material and Methods

A systematic review of the literature was performed to evaluate all clinical studies describing techniques or outcomes of neuromonitoring or neuroprotective strategies implemented during pediatric cardiac surgical procedures involving CPB, including studies with extension of monitoring immediately prior to (within 24 hours) or after operations (within 48 hours). A panel of 9 individuals was convened, including specialists in pediatric cardiac surgery (7), pediatric anesthesiology (1), and

Results

Based on the established search criteria, a total of 162 manuscripts were identified that met the eligibility criteria (Fig 1). For initial organization and distribution for scoring, manuscripts were placed into 13 categories based on the primary type of neuromonitoring or neuroprotection being employed (Table 1). The baseline characteristics of the overall body of literature include median sample size of 43 (range 3 to 2,481) with 43% (n = 69) of articles having a neurologic outcome as a

Comment

“Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” [11]. The systematic review is a formal process to identify and evaluate primary studies and other research to make determinations about effectiveness of particular

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Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.