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Ann Thorac Surg 1999;68:160-163
© 1999 The Society of Thoracic Surgeons

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Original Articles

Peritoneal dialysis after infant open heart surgery: observations in 27 patients

^a Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany

Address reprint requests to Dr Dittrich, Deutsches Herzzentrum Berlin, Abteilung Angeborene Herzfehler/Kinderkardiologie, Augustenburger Platz 1, D-13353 Berlin, Germany
e-mail: svsdittr{at}aol.com

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. The role of peritoneal dialysis (PD) in the management of infants after heart operation is under discussion. The aim of this study was to investigate the effect of PD on fluid balance and outcome.

Methods. Twenty-seven (33%) of 81 consecutive infants who underwent heart operation required PD. In 22 patients (81%), PD was started prophylactically at the end of the operation. We recorded hemodynamic data and fluid balance. Patients experiencing acute renal failure (ARF) were compared with the remaining infants.

Results. Eleven of 81 patients (14%) experienced ARF; 3 of them died (4% of all patients undergoing operation, 27% of those with ARF). Complications of PD, present in 33%, were transitory and of minor significance. Patients with ARF had decreased cardiac function compared with those without ARF but similar fluid balance.

Conclusions. Peritoneal dialysis is an effective and safe method for the treatment of ARF in infants after open heart operation. As PD is helpful in modulating postoperative fluid balance, prophylactic use of PD can be recommended for selected patients who are at risk for low cardiac output syndrome.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Acute renal failure (ARF) resulting from low cardiac output is a well-known and severe complication after congenital open heart operation and has been associated with high mortality in a number of studies [1–5]. Despite much progress in cardiac operation and intensive care techniques, the incidence of ARF has changed little during the last decade and is reported to range from 2.4% to 8% [1–6].

Various therapeutic strategies for ARF may be applied: mild forms may be treated with fluid restriction, increase of filtration pressure by raising the mean arterial pressure, and the application of diuretics [5]. More severe cases require hemofiltration [4, 7, 8] or peritoneal dialysis (PD) [3, 5, 9]. However, in contrast to PD, hemofiltration in infants has some major disadvantages: the difficulty of securing line access, the difficulty of proper return, and the requirement of systemic anticoagulation with its inherent risk [8].

The role of PD in postoperative therapy, technical details of applying it, such as optimal timing of PD, and its complications are currently under discussion [5, 9, 10]. To evaluate the PD management at our institution, we investigated all infants younger than 1 year prospectively in a 9-month period.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between April and December 1996, 366 patients underwent operations for congenital heart disease (Table 1). All patients younger than 1 year who received PD and survived cardiopulmonary bypass operation longer than 24 hours were included into the study. The documentation of data was approved by the bedside patient data record system (EMTEC, Motorola and Siemens Medical Systems, Munich, Germany). Acute renal failure was defined as urine output less than 0.5 mL/kg per hour for more than 4 hours; unresponsive to adjustment in fluid therapy, diuretics, or inotropic support; a serum creatinine level greater than 1.2 mg/dL; or any combination thereof.

A standard Dacron-cuffed silicone rubber peritoneal catheter (Tenckhoff, Sherwood Medical GmbH, Schwalbach, Germany) was inserted surgically through an infraumbilical midline or a paraumbilical left-sided approach either during the primary surgical procedure, especially in case of long cardiopulmonary bypass time, long circulatory arrest time, low cardiac output, or delayed closure of sternotomy, or in the intensive care unit when postoperative hemodynamic and renal complication was anticipated. Standard dialysate solutions were prepared under sterile conditions at our pharmacy. We used a closed irrigation/drainage system. In cases of clinically suspected patient infection, the dialysate was examined microbiologically. Initially a 3% lactate-free solution (Table 2) and a low-volume dialysis technique with 10 mL/kg body weight irrigation, 10 minutes indwelling time, and 20 to 50 minutes drainage time was used. Dialysis schedule was altered regularily according to clinical and biochemical status.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
During the study period, 291 patients underwent cardiopulmonary bypass operations (Table 1), among them 81 infants younger than 1 year (28%). Twenty-one patients experienced ARF (7% of all patients). Among the 81 infants younger than 1 year, 11 (14%) had ARF (Table 1); 3 of them died (4% of all patients, 27% of those with ARF, Table 3). The deaths were related to arterial switch operation (n = 1), correction of a common arterial truncus (n = 1), and complete atrioventricular septal defect, which required mitral valve reconstruction some days after primary correction (n = 1). All 3 patients had severe congestive heart failure. Ventricular tachycardia occured in 1 patient, who had acute hyperkalemia with maximum serum values of 6.5 mmol/L.

An effective fluid withdrawal could be achieved in all infants (Tables 3, 4). Patients with ARF had significantly reduced diuresis, elevated serum creatinine levels, and elevated central venous pressures and received increased epinephrine dosages compared with those without ARF (Table 4). Fluid intake, heart rates, and mean arterial pressures did not differ significantly. Peritoneal dialysis resulted in a similar favorable low positive fluid balance in both groups during the first days after operation (Table 4). Serum sodium, potassium, calcium, and phosphate levels remained within normal range in all patients (Table 4).

A total of 17 complications in 10 patients (39% of all PD) were observed (Table 5). We had no positive dialysate cultures. A suspected septic situation in 2 patients, each with sterile blood cultures, tracheal secretion, urine cultures, and peritoneal fluids, were nevertheless considered as possible complications of PD. All observed hemorrhages into the peritoneal outflow ceased spontaneously; they were, however, also considered as complications because of unmeasurable blood loss.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
In line with other centers [1, 3, 5, 9], we have developed a low threshold for using PD after open heart operation in young infants and applied the technique from the beginning of our clinical work in 1988. However, because criteria of indication for PD, the best timing for its application in postoperative therapy, and evaluation of risk factors are the subject of ongoing controversial discussion [5, 9, 10], our strategy needed a critical reflection. The introduction of the bedside EMTEC patient data documentation system at our institution in April 1996 provided optimal support for performing this work.

Parallel to our study, Werner and associates [5] studied the benefits and complications of PD through a postoperatively percutaneously placed PD catheter. Like other groups before [1–3, 9], these authors considered PD as a safe technique, although some severe complications such as bacterial peritoneal infection and bowel perforations had arisen. In contrast [1, 5, 10], we encountered no severe mechanical complications nor any proven infection (Table 5) in the study period. Even if unclear infection syndromes are included, the risk of infection of short-term dialysis seems low (Table 4). Our use of a closed irrigation/drainage system [10, 11] probably accounts for a low infection rate. A long-range, percutaneously tunneled approach to the peritoneal cavity [10], as is usually applied in the case of long-term PD [11], is not necessary for short-term dialysis in our experience.

The use of the low-volume PD technique (10 mL/kg cycled each hour) [9, 10], a low osmolarity dialysate fluid (Table 2) [2, 5], and a short indwelling time may have attributed to a low peritoneal irritation and infection rate and furthermore caused less acute hemodynamic disturbances than the 15% incidence described elsewhere [5].

Nevertheless our PD technique allowed an effective dialysis and an effective withdrawal of fluid (Tables 3, 4). One death in a patient with congestive heart failure and ARF was related to acute hyperkalemia, but in general PD proved to be effective at keeping potassium levels in the normal range (Table 4). We demonstrated that children undergoing PD had a continuous improvement in hemodynamics, as evidenced by rising mean arterial blood pressure, decreasing central venous pressure, and decreasing requirement for inotropic support (Table 4). These results support recent evidence [4, 5, 7] suggesting that active fluid removal in patients with ARF and low cardiac output may improve hemodynamics. Positive impact on ventilation parameters have been shown recently [5]. However, neither those studies nor ours included a control group, and thus the observed effects might have been caused by time only.

Despite being an effective therapy of ARF (Tables 3, 4), the benefit of PD lies in the favorable influence on fluid balance as shown in those 60% of PD-treated patients in our study who did not have ARF (Tables 3, 4) [2, 4, 5, 9].

The frequency of ARF in our study (Table 1) is comparable with other centers [1–5], although the 27% mortality rate in our study group seems low compared with mortality rates between 33% and 79% reported by others [1–5]. This may be because of the early onset of PD (81% prophylactically implanted PD catheters in the group of patients with ARF) whereas most other groups started PD later [1–5]. It is possible that the prophylactic and early start of dialysis treatment lowers the mortality through early impact on the fluid balance, but to draw conclusions, a controlled randomized trial for the use of PD in infants is required [5].

Our prospectively gathered data demonstrate the hemodynamic benefit of PD, underlying the value of a prophylactic and carefully managed PD for the postoperative fluid balance and for the prevention of the detrimental effects of ARF, which may be one reason for a comparatively low mortality rate [1–5]. Thus, we conclude that early application of PD in selected patients [12] who are at risk of low cardiac output syndrome after cardiopulmonary bypass operation in congenital heart disease is beneficial.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Baxter P., Rigby M., Jones O., Lincoln C., Shinebourne E. Acute renal failure following cardiopulmonary bypass in children. Int J Cardiol 1985;7:235-239.[Medline]
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8. Fleming F., Bohn D., Edwards H., et al. Renal replacement therapy after repair of congenital heart disease in children. J Thorac Cardiovasc Surg 1995;109:322-331.[Abstract/Free Full Text]
9. Mee R.B.B. Invited letter concerning. J Thorac Cardiovasc Surg 1992;103:1021-1022.[Medline]
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Vladimir Alexi-Meskishvili Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dittrich, S. Articles by Lange, P. E. Search for Related Content PubMed PubMed Citation Articles by Dittrich, S. Articles by Lange, P. E.