The impact of remote ischemic preconditioning on postoperative outcomes in pediatric cardiac surgery: an updated systematic review and meta-analysis.

UNLABELLED: Remote ischemic preconditioning (RIPreC) has been regarded as a promising strategy to reduce ischemia-reperfusion injury to the heart and other organs caused by cardiopulmonary bypass. While RIPreC has demonstrated potential benefits in adult cardiac surgery, particularly in reducing postoperative kidney and cardiac dysfunction, evidence in pediatric populations remains limited and inconsistent. This updated systematic review and meta-analysis aims to address these gaps and clarify the efficacy of RIPreC in children undergoing cardiac surgery. A comprehensive search was conducted across PubMed, EMBASE, Cochrane Library, Web of Science, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing RIPreC with placebo or standard care in pediatric cardiac surgery. Primary outcomes included all-cause mortality, duration of mechanical ventilation, ICU length of stay, aortic cross-clamp time, and postoperative arrhythmia. Meta-analyses were performed using random-effects models to calculate standardized mean differences (SMDs) or risk ratios (RRs), with 95% confidence intervals (CIs). Risk of bias was assessed using the Cochrane RoB 2.0 tool. Fifteen RCTs involving 1570 pediatric patients were included, and 14 were eligible for meta-analysis. RIPreC significantly reduced the duration of mechanical ventilation compared to control (SMD = -0.42; 95% CI -0.79 to -0.06; p = 0.02), although heterogeneity was high (I2 = 85.7%). No significant differences were found for ICU length of stay (MD = -0.17 days; 95% CI -0.55 to 0.20), aortic cross-clamp time (MD = 3.22 min; 95% CI -0.52 to 6.97), postoperative arrhythmia (RR = 0.69; 95% CI 0.39 to 1.20), or all-cause mortality (RR = 1.11; 95% CI 0.34 to 3.64).

CONCLUSION

RIPreC may reduce the duration of mechanical ventilation in pediatric cardiac surgery, but its effects on other outcomes remain uncertain. Further, high-quality trials are warranted to strengthen the evidence base and guide clinical application.

WHAT IS KNOWN: • Remote ischemic preconditioning (RIPreC) is a promising technique to protect organs from ischemia-reperfusion injury during cardiac surgery. While its benefits have been more consistently observed in adult populations, evidence regarding its efficacy in pediatric cardiac surgery remains limited and inconclusive.

WHAT IS NEW: • This updated systematic review and meta-analysis provides the most comprehensive evaluation to date of RIPreC in children undergoing cardiac surgery, clarifying its potential effects on postoperative cardiac and renal outcomes. • Our findings support further investigation of RIPreC in pediatric patients through high-quality trials and suggest it may be a beneficial adjunct to improve postoperative outcomes in pediatric cardiac surgery settings.