Prophylactic steroids for pediatric open heart surgery

Mahmoud Elbarbary, Wedad H Madani, Suzanne Robertson‐Malt

The immune response to cardiopulmonary bypass in infants and children can lead to a series of postoperative morbidities and mortality i.e. hemodynamic instability, increased infection and arrhythmias. The systemic Inflammatory response syndrome (SIRS) that may develop post bypass can affect the outcome. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate the pro-inflammatory response of SIRS. However, the clinical benefits and harms of this type of intervention in the pediatric patient remains uncertain. Is to update the previously published review "Prophylactic steroids for pediatric open heart surgery" which systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in pediatric open heart surgery. The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2014, issue 1); MEDLINE (1966 to October 2014); EMBASE (1980 to October 2014); CINAHL (1964 to October 2014) were searched. An additional hand search of the EMRO database for Arabic literature was performed. Grey literature was searched and experts in the field were contacted for any unpublished material. No language restrictions were applied. All randomized and quasi-randomized controlled trials of open heart surgery in the pediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality. Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan 5.2 We calculated the risk ratio (RR) with 95% confident intervals (CI) for comparing the outcomes between groups. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model. Two trials were added in the updated review namely Lerzo 2011 with 29 participants and Keski-Nisula 2013 with 40 participants, that makes total studies of seven with total number of participants is 226. All studies are in general with poor quality due mainly to small sample size according to the Cochrane Handbook section(Chapter 12). Despite it did not reach statistical significance and more research is needed. There was trend in favor of prophylactic corticosteroid administration for reducing intensive care length of stay WMD (-0.38 )days (95% CI -1.23 to 0.46), peak core temperature -0.17°C (-0.93 to 0.59)there is no evidence to suggest effect of steroids in peak core temperature; duration of ventilation -0.63 hours (-4.01 to 2.75) there is no evidence to suggest effect of steroids in total hours ventilated; and reduction in mortality OR of 0.57 (0.02 to 13.19). There was no reported increase in the side effects particularly regarding infection, wound healing and GIT bleeding. The use of prophylactic steroids in pediatric patients to reduce postoperative complications commonly experienced following cardiopulmonary bypass surgery is not supported by the existing evidence despite the trend in favour. Further well designed and adequately powered randomized controlled trials are needed to more accurately estimate the benefit and harm of this intervention.