Analysis of P(v-a)CO2/C(a-v)O2 Ratio and Other Perfusion Markers in a Population of 98 Pediatric Patients Undergoing Cardiac Surgery

Abstract

Background: The so-called Low Cardiac Output Syndrome (LCOS) is one of the most common complications in pediatric patients with congenital heart disease undergoing corrective surgery. LCOS requires high concentrations of inotropes to support cardiac contractility and improve cardiac output, allowing for better systemic perfusion. To date, serum lactate concentrations and central venous oxygen saturation (ScVO₂) are the most commonly used perfusion markers, but they are not completely reliable in identifying a state of global tissue hypoxia. The study aims to evaluate whether the venoarterial carbon dioxide difference/arterial-venous oxygen difference ratio [P(v-a)CO₂/C(a-v)O₂] can be a good index to predict the development of LCOS in the aforementioned patients, so as to treat it promptly.

Methods: This study followed a population of 98 children undergoing corrective cardiac surgery from June 2018 to October 2020 at the Department of Cardiac Surgery of University Hospital Integrated Trust and their subsequent admission at the Postoperative Cardiothoracic Surgery Intensive Care Unit. During the study, central arterial and venous blood gas analyses were carried out before and after cardiopulmonary bypass (CPB) (pre-CPB and post-CPB), at admission to the intensive care unit, before and after extubation, and at any time of instability or modification of the patient's clinical and therapeutic conditions.

Results: The data analysis shows that 46.9% of the children developed LCOS (in line with the current literature) but that there is no statistically significant association between the P(v-a)CO₂/C(a-v)O₂ ratio and LCOS onset. Despite the limits of statistical significance, however, a 31% increase in the ratio emerged from the pre-CPB phase to the post-CPB phase when LCOS is present.

Conclusions: This study confirms a statistically significant association between the most used markers in adult patients (serum lactate concentration, ScVO₂, and oxygen extraction ratio-ERO₂) measured in the pre-CPB phase and the incidence of LCOS onset, especially in patients with hemodynamic instability before surgery.

Keywords: cardiopulmonary bypass; congenital heart disease; infant; physiologic monitoring; postoperative care; venoarterial carbon dioxide difference.

Figure 1

Interaction plot for P(v-a)CO₂/C(a-v)O₂ in relation to Low Cardiac Output Syndrome (LCOS) onset (0 = no development of LCOS; 1 = development of LCOS) in the two subgroups of cyanotic (left) and acyanotic (right) at different sampling times. Abbreviations: A-pre-CEC: at anesthesia induction (pre-CPB), B-post-CEC: at CPB discontinuation, C-admUTI: upon intensive care unit admission, D-pre-estub: before extubation, E-post-Estub: after extubation.

Figure 2

Interaction plot for lactate in relation to Low Cardiac Output Syndrome (LCOS) onset (0 = no development of LCOS; 1 = development of LCOS) in the two subgroups cyanotic (left) and acyanotic (right) at the different sampling times. Abbreviations: A-pre-CEC: at anesthesia induction (pre-CPB), B-post-CEC: at CPB discontinuation, C-admUTI: upon intensive care unit admission, D-pre-estub: before extubation; E-post-Estub: after extubation.

Figure 3

Interaction plot for ScVO₂ in relation to Low Cardiac Output Syndrome (LCOS) onset (0 = no development of LCOS; 1 = development of LCOS) in the two subgroups cyanotic (left) and acyanotic (right) at the different sampling times. Abbreviations: A-pre-CEC: at anesthesia induction (pre-CPB), B-post-CEC: at CPB discontinuation, C-admUTI: upon intensive care unit admission, D-pre-estub: before extubation; E-post-Estub: after extubation.

Figure 4

Interaction plot for ERO₂ in relation to Low Cardiac Output Syndrome (LCOS) onset (0 = no development of LCOS; 1 = development of LCOS) in the two subgroups cyanotic (left) and acyanotic (right) at the different sampling times. Abbreviations: A-pre-CEC: at anesthesia induction (pre-CPB), B-post-CEC: at CPB discontinuation, C-admUTI: upon intensive care unit admission, D-pre-estub: before extubation; E-post-Estub: after extubation.

Figure 5

Interaction plot for ∆P(v-a)CO₂ in relation to Low Cardiac Output Syndrome (LCOS) onset (0 = no development of LCOS; 1 = development of LCOS) in the two subgroups cyanotic (left) and acyanotic (right) at the different sampling times. Abbreviations: A-pre-CEC: at anesthesia induction (pre-CPB), B-post-CEC: at CPB discontinuation, C-admUTI: upon intensive care unit admission, D-pre-estub: before extubation; E-post-Estub: after extubation.