Echo Rowe

All Publications

• The Impact of Utilizing Combined Factor Concentrates for Hemostasis Management in Pediatric Pulmonary Artery Reconstruction: A Propensity Score-Matched Cohort Study. Paediatric anaesthesia Flannery, K. M., Dietrich, C. A., Rowe, E. V., Mendoza, J. M., Shen, S., Hanley, F. L., Margetson, T., Navaratnam, M. 2026

  Abstract

  Bleeding after cardiopulmonary bypass in pediatric patients undergoing pulmonary artery reconstruction is a major source of morbidity. Factor concentrates have emerged as off-label therapy to achieve hemostasis while minimizing transfusion. In 2020, our institution implemented a standardized hemostasis management pathway combining factor concentrates.This study evaluates the impact of the pathway on blood product transfusion and thromboembolism for patients undergoing pulmonary artery reconstruction with cardiopulmonary bypass.We conducted a retrospective propensity score-matched cohort study comparing pediatric patients undergoing pulmonary artery reconstruction before and after pathway implementation. The pre-pathway cohort received activated 4-factor prothrombin complex concentrate for refractory bleeding with variable dosing, whereas the post-pathway cohort received both fibrinogen and activated 4-factor prothrombin complex concentrates in standardized doses. The primary efficacy outcome was total blood product transfused after cardiopulmonary bypass. The primary safety outcome was thromboembolism incidence at seven and 30 days postoperatively. Secondary outcomes included 24-h chest tube output, time to extubation, length of stay, 30-day mortality, and acute kidney injury.A total of 97 pre-pathway patients and 178 post-pathway patients were included in the final data set for statistical analysis. After propensity score matching, 87 patients remained in each cohort. The post-pathway cohort was associated with a statistically significant reduction in total blood products transfused (30.4 mL/kg vs. 47.9 mL/kg, mean difference 17.6 mL/kg, 95% CI [9.82-25.9], p < 0.0001). There was no statistically significant difference in seven-day (11.5% post-pathway vs. 8.0% pre-pathway, OR 1.48, 95% CI 0.51-4.32, p = 0.468) or 30-day (18.4% post-pathway vs. 9.2% pre-pathway, OR 2.23, 95% CI 0.84-5.87, p = 0.106) thromboembolism rates. There were no significant differences in secondary outcomes.A hemostasis management pathway utilizing combined factor concentrates was associated with significantly reduced post-bypass transfusion requirements in pediatric pulmonary artery reconstruction. We observed a higher incidence of post-operative thromboembolism, with a twofold increase at 30 days, although statistical significance was not reached. The majority of post-operative thromboembolism was associated with indwelling lines. Prospective multicenter studies are needed to validate safety, efficacy and generalizability of utilizing combined factor concentrates in pediatric patients.

  View details for DOI 10.1002/pan.70201

  View details for PubMedID 42028999

• Hemodynamic Effects of Altering Tidal Volume During Positive Pressure Ventilation in the Fontan Circulation: A Randomized Crossover Trial. Paediatric anaesthesia Navaratnam, M., Schmidt, A. R., Kaplinski, M., De Souza, E., Beattie, M. J., Rowe, E. V., Punn, R., Ramamoorthy, C. 2025

  Abstract

  Primary determinants of pulmonary blood flow in the Fontan circulation are low transpulmonary gradient and pulmonary vascular resistance (PVR). Changes in intrathoracic pressure during intermittent positive pressure ventilation can influence the transpulmonary gradient, PVR, pulmonary blood flow, and cardiac output. The aim of this study was to evaluate the effect of low (5 mL/kg) versus high (10 mL/kg) tidal volume (VT) ventilation on Fontan circulation hemodynamics.Postoperative patients with a Fontan circulation were enrolled in this single-center, randomized crossover trial. Patients, randomized to group 1 or 2, underwent a ventilation study sequence (baseline ventilation [7 mL/kg], then high VT [10 mL/kg] or low VT [5 mL/kg], then washout ventilation [7 mL/kg], followed by low [5 mL/kg] or high VT [10 mL/kg]) in the operating room at the end of the cardiac surgical procedure. Respiratory, hemodynamic, and transesophageal (TEE) measurements were recorded after 5 min in each ventilation condition. The primary aim of this study was to evaluate the effect of low VT ventilation (5 mL/kg) versus high VT ventilation (10 mL/kg) on transpulmonary gradient (Fontan pressure minus left atrial pressure). The secondary aim was to compare TEE measurements of pulmonary blood flow, stroke volume, and Fontan flow between low and high VT ventilation. We also compared standard hemodynamic and ventilation parameters for all ventilation conditions. Analysis was of paired data, calculating the between-treatment difference within participants across ventilation conditions.Eleven patients were included in the final data analysis with a median [IQR] age of 5 [4, 11] years and weight of 16.3 [13.8, 31.6] kg. The mean (±SD) peak inspiratory pressure during low and high VT ventilation was 15.3 (±2.9) cmH2O and 22.2 (±3.7) cmH2O, respectively (difference -6.9, 95% CI -7.8, -5.9, p < 0.001). The mean airway pressure during low and high VT ventilation was 7.3 ± 0.8 and 8.7 ± 0.9 (difference -1.5, 95% CI -2.1, -0.8, p = 0.001) with a mean inspiratory time of 0.62 (±0.22) s and 1.21 (±0.55) s (difference -0.59, 95% CI -0.84, -0.34, p < 0.001), respectively. During low VT ventilation, the mean Fontan pressure was 13.3 (±1.8) mmHg compared to 12.3 (±2.5) mmHg for high VT ventilation (difference 0.8, 95% CI -0.5, 2.1, p = 0.18). The mean transpulmonary gradient was 7.0 ± 1.3 mmHg compared to 6.8 ± 1.2 mmHg during low and high VT ventilation, respectively (difference 0.2, 95% CI -0.2, 0.6, p = 0.21). We found no significant differences between low and high VT ventilation in TEE measures of pulmonary blood flow, stroke volume, and Fontan flow.This randomized, crossover pilot trial of Fontan patients showed that a low VT ventilation (5 mL/kg) resulted in significantly lower peak and mean airway pressure compared with a high VT ventilation (10 mL/kg). However, there were no significant changes in transpulmonary gradient, mean Fontan pressure, or TEE parameters of stroke volume, pulmonary blood flow, or Fontan flow.NCT04633343.Manchula Navaratnam.November 11, 2020. Clinical Trials Registration Registry URL: https://clinicaltrials.gov/study/NCT04633343?term=Fontan%20ventilation&rank=3.Congenital Cardiac Anesthesia Society Annual Meeting Top Oral Abstract Presentation.Alexander R Schmidt, March 30th, 2023.

  View details for DOI 10.1111/pan.15096

  View details for PubMedID 40105302

• Hydroxocobalamin to treat refractory vasoplegia following phaeochromocytoma resection in a child. Anaesthesia reports Giustini, A. J., Rowe, E. V., Perez, F. D., Mihm, F. G. 2022; 10 (2): e12201

  Abstract

  Phaeochromocytomas and paragangliomas are rare neuroendocrine tumours that often secrete catecholamines, which can cause dramatic swings in blood pressure and end-organ damage. During surgical resection of these tumours, antihypertensive drug infusions are often required, but after resection patients may become vasoplegic, in part due to cessation of catecholamine secretion by the tumour in the context of pre-operative alpha1 adrenoceptor antagonism. Numerous medications have been used to treat vasoplegia in this setting, including noradrenaline, vasopressin and, more recently, angiotensin II. We report the case of a patient who experienced vasoplegia after phaeochromocytoma resection which was refractory to vasopressin and angiotensin II infusions but was successfully treated with high dose hydroxocobalamin.

  View details for DOI 10.1002/anr3.12201

  View details for PubMedID 36523482

• Clinical Practice Guideline: Maintenance Intravenous Fluids in Children PEDIATRICS Feld, L. G., Neuspiel, D. R., Foster, B. A., Leu, M. G., Garber, M. D., Austin, K., Basu, R. K., Conway, E. E., Fehr, J. J., Hawkins, C., Kaplan, R. L., Rowe, E. V., Waseem, M., Moritz, M. L., Subcomm Fluid Electrolyte Therapy 2018; 142 (6)

  View details for DOI 10.1542/peds.2018-3083

  View details for Web of Science ID 000451372200059

• Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics Feld, L. G., Neuspiel, D. R., Foster, B. A., Leu, M. G., Garber, M. D., Austin, K., Basu, R. K., Conway, E. E., Fehr, J. J., Hawkins, C., Kaplan, R. L., Rowe, E. V., Waseem, M., Moritz, M. L., SUBCOMMITTEE ON FLUID AND ELECTROLYTE THERAPY 2018

  Abstract

  Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children.The Key Action Statement of the subcommittee is as follows:1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong).

  View details for PubMedID 30478247