Acute gastrointestinal injury after pediatric cardiac surgery: A single-center prospective observational study

Acute gastrointestinal injury after pediatric cardiac surgery: A single-center prospective observational study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Acute gastrointestinal injury after pediatric cardiac surgery: A single-center prospective observational study Shouping Wang, Wang Niu, Jiarong Zeng, Lijing Deng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8372476/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Acute gastrointestinal injury (AGI) encompasses structural or functional gastrointestinal tract dysfunction arising from various stress conditions in critically ill patients. Although it is a well recognized complication in adult cardiovascular surgery patients, its prevalence and risk factors in pediatric population remain unclear. This study sought to: (1) investigate the incidence and prognostic influence of AGI, and (2) identify the risk factors and clinical characteristics associated with AGI in pediatric patients undergoing open-heart surgery with cardiopulmonary bypass(‌CPB). Methods This was a prospective observational study conducted in a single center. The pediatric patients undergoing open-heart surgery with CPB between April 2021 and December 2021 were included. Data collection included demographics, operative details, gastrointestinal symptoms, intra-abdominal pressure(IAP), anthropometric parameters of abdominal morphology, and clinical outcomes. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for AGI. A P-value < 0.05 was considered statistically significant. Results Analysis of 137 pediatric patients revealed that AGI occurred in 60 patients (43.8%) following open-heart surgery with CPB. Patients with AGI experienced a higher rates of low cardiac output syndrome(LCOS), postoperative infections, and composite outcome (P < 0.05). Furthermore, these patients required greater vasopressor support and experienced longer durations of mechanical ventilation and ICU/hospital stays. Multivariable logistic regression identified AGI as an independent risk factor for the composite outcome (odds ratio [OR] 3.44, 95% confidence interval [CI] 1.28 ~ 9.27; P = 0.015). Multivariate analysis also identified a longer ‌CPB time (OR 1.01, 95% CI: 1.00 ~ 1.02; P = 0.007) and a higher intraoperative Vasoactive-Inotropic Score (VIS) (OR 1.11, 95% CI: 1.02 ~ 1.20; P = 0.013) as independent perioperative risk factors for AGI. Postoperative abdominal morphology demonstrated significant alterations, which were more pronounced in the AGI group. Conclusion AGI represents a significant clinical concern in pediatric cardiac surgery, where its presence is consistently linked to an adverse postoperative outcome. Prolonged CPB duration and high-dose intraoperative vasoactive drug administration are potential predictive factors for AGI development. Notably, early postoperative alterations in abdominal anthropometric measurements may provide an early non-invasive warning indicator for AGI identification, enabling timely intervention and potentially improving clinical outcomes. Trial registration ClinicalTrials.gov Identifier ChiCTR2100044840 on March 30, 2021 Acute gastrointestinal injury Pediatric patients Prognosis Figures Figure 1 1. Introduction Congenital heart disease (CHD) accounts for approximately 28% of all congenital anomalies [ 1 ] , with a global prevalence of 8 per 1000 live births [ 2 – 4 ] . CHD significantly impacts ‌the survival, neurodevelopment and overall quality of life on affected children [ 5 – 6 ] ,‌while also imposing substantial physical and psychological burdens on their parents‌ [ 7 ] . Surgical correction with CPB represents the primary therapeutic approach for pediatric patients with severe forms of CHD. During CPB, the gastrointestinal tract is highly susceptible to damage due to factors such as hypoxia, hypoperfusion, stress, ischemia-reperfusion injury, and systemic inflammatory response [ 8 – 10 ] . Over the past three decades, the gastrointestinal tract has been increasingly recognized as a pivotal "engine" driving multiple organ dysfunction in critical ill patients [ 11 ] . In 2012, the European Society of Intensive Care Medicine (ESICM) established a standardized four-grade classification system for AGI identification in critically ill patients [ 12 ] . This grading system, where higher grades reflect more severe gastrointestinal damage and worse clinical outcomes, has been widely adopted in clinical practice. With a reported incidence of 67.3% [ 13 ] , AGI is a common complication in adult cardiac surgery patients, and its pathogenesis involves a spectrum of risk factors [ 14 – 15 ] . However, AGI remains understudied in pediatric population, and its risk factors remain unclear. This prospective observational study aims to: (1) investigate the incidence and prognostic influence of AGI, and (2) identify the risk factors and clinical characteristics associated with AGI in pediatric patients undergoing open-heart surgery with CPB. 2. Methods 2.1. Study design This prospective single-center observational study received approval from the Biomedical Research Ethics Committee of West China Hospital, Sichuan University (Approval No. 2020(1227)) on February 25, 2021. The trial was registered at the Chinese Clinical Trial Registry ( https://www.chictr.org.cn , Registration No. ChiCTR2100044840) before participant enrollment. Written informed consent was obtained from all legal guardians of pediatric participants before inclusion. Data and safety were monitored at regular 3-month intervals. The study adhered to the principles of the World Medical Association's Declaration of Helsinki and followed Good Clinical Practice standards [ 16 ] . Pediatric patients (< 14 years) undergoing selective open-heart surgery with CPB were eligible for participation. Children with preoperative gastrointestinal disorders were excluded. Patients were divided into AGI or non-AGI groups based on criteria defined by the European Society of Intensive Care Medicine [ 12 ] . 2.2. Study Procedures Screening for eligibility was completed before the clinical evaluation. The following data were monitored and recorded: demographics, operation-related information, postoperative digestive symptoms, intra-abdominal pressure (IAP), abdominal diameter, ultrasonic measurement of intestinal diameter and postoperative complications. 2.3. Assessed variables 2.3.1. Monitoring and evaluation of gastrointestinal function Longitudinal monitoring of gastrointestinal symptoms and signs was performed by trained clinicians, with assessments commencing upon ICU admission and continuing for the subsequent 3 days. Researchers investigated cases of AGI based on the clinical characteristics and examination results. The electronic medical record system was also reviewed to ensure that important gastrointestinal symptoms and signs were not missed. According to the European Society of Critical Care Medicine [ 12 ] , postoperative conditions which manifested as vomiting, diarrhoea, feeding intolerance, gastric residuals, gastrointestinal bleeding, absent peristalsis, paralysis of lower gastrointestinal tract, necrotizing enterocolitis and intra-abdominal hypertension were considered AGI. Of these gastrointestinal conditions, vomiting was defined as “the occurrence of any visible regurgitation of gastric content irrespective of the amount”. Diarrhoea was defined as “stool property changed, such as sparse stool and watery stool”. Feeding intolerance was defined as “digestive disorder after enteral feeding, which leads to abdominal distension, vomiting, gastric retention”. Gastric residuals was defined as “the gastric remnant is greater than 50% of the previous feeding amount”. GI bleeding was defined as “any bleeding into the GI tract lumen, confirmed by macroscopic presence of blood in vomited fluids, gastric aspirate or stool”. Absent peristalsis was defined as “no bowel sounds are heard at cautious auscultation”. Paralysis of lower GI tract was defined as “the inability of the bowel to pass stool due to impaired peristalsis. Necrotizing enterocolitis (NEC) was defined as “an acute reduction in the supply of oxygenated blood to the small intestine or large intestine, typically resulting in acidosis, abdominal distention, pneumatosis, and/or intestinal perforation, that prompts initiation of antibiotics or exploratory laparotomy”. Intra-abdominal hypertension (IAH) was defined as “a persistent or repeated increase in IAP greater than 10mmHg” [ 17 ] . The severity and diagnostic criteria of AGI:‌ Grade I, increased risk of gastrointestinal dysfunction(self-limiting); Grade II, gastrointestinal dysfunction requiring intervention; ‌Grade III‌, gastrointestinal failure unresponsive to treatment; ‌Grade IV, life-threatening gastrointestinal failure. 2.3.2. The measurement of intra-abdominal pressure IAP was measured by trained nursing staff according to a standardized protocol [ 17 ] via a commercially available pressure transducer (DPT-248, China). Measurements were obtained at the time of admission, and 12h, 24h thereafter. IAP was measured in mmHg via a urinary catheter connected to a standard invasive pressure monitoring system with a three-way stopcock. With the patient in complete supine position, the transducer was zeroed at the level of the mid-axillary line and the iliac crest. After ensuring the absence of abdominal muscle contraction, the bladder was instilled with 1 mL/kg of sterile saline (range of 3 ~ 25 mL). Following a 30 ~ 60 seconds stabilization period at end-expiration, the IAP value was recorded from the bedside monitor. 2.3.3. The enteral feeding practice After transfered to the ICU, enteral nutrition (EN) was initiated in all patients while achieving hemodynamic stability, defined as the absence of exacerbated vasopressor support, low cardiac output, or evidence of oxygen supply-demand imbalance. EN was commenced at a trophic rate of 16 mL/kg/day and advanced gradually according to tolerance. The gastric tube was removed following extubation once the patient's ability for adequate oral intake was confirmed. 2.3.4. The anthropometric measurements of abdominal morphology Trained physicians evaluated the anthropometric measurements of abdominal morphology which used in several previous studies [ 18 – 19 ] . Abdominal perimeter (AP) is the abdominal circumference at its largest point (usually at the level of the umbilicus). Hip circumference is the largest horizontal girth between waist and thigh. Waist circumference is the smallest horizontal girth between the rib cage and iliac crest. Sagittal abdominal diameter or abdominal short axis is the height between the table or bed and the apex of the abdomen, while the transverse abdominal diameter or abdominal long axis is the distance between the both sides of abdominal walls perpendicular to the horizontal plane of the sagittal abdominal diameter or abdominal short axis), and finally calculated abdominal volume index (AVI, caculated as [2 × [Waist] 2 + 0.7 × ([Waist]–[Hip]) 2 ]/1000. Nursing staff recorded these anthropometric data at patients admission and 12-hour intervals thereafter using soft rulers and vernier calipers. Meanwhile, physicians performed abdominal ultrasound (Mindray, 35C50EB, 5.0-7.5 MHz convex transducer) to measure intestinal diameters. Jejunal diameter was assessed 1 cm distal to the Treitz ligament, and ascending colon diameter was measured 1 cm proximal to the ileocecal valve. The convex probe was placed in the left upper abdomen for clockwise scanning, with optional 90°rotation for enhanced horizontal sliding to visualize the jejunum. For colonic assessment, longitudinal scanning along the descending colon was performed. 2.4. Investigator training, data collection, and outcome measures Prior to trial initiation, investigators (Shouping Wang, Wang Niu) responsible for data collection and follow-up assessments received standardized training from the principal investigator (Lijing Deng) on assessment protocols, including AGI definition evaluation and postoperative composite outcome assessment. Baseline data collected included demographics, IAP, abdominal morphology anthropometrics, and intestinal diameters. Intraoperative data encompassed extracorporeal circulation duration and vasoactive-inotropic score (VIS), calculated as:VIS = Dopamine + Dobutamine + 10×Milrinone + 100×Adrenaline + 100×Norepinephrine + 10,000×Pituitrin (all in ug/kg/min)‌.The study utilized intraoperative VIS max and postoperative VIS 24hmax to quantify vasoactive drug intensity.Postoperative monitoring included GI symptoms and in-hospital composite outcome [ 20 ] , defined as any of death, cardiac arrest, ECMO, hepatic/renal insufficiency, or lactic acidosis. Additional recorded outcomes comprised low cardiac output syndrome (LCOS), infections, and neurological complications. Primary outcomes‌ focused on postoperative AGI incidence and its prognostic influence on clinical outcomes. Secondary outcomes‌ identified the risk factors and clinical characteristics associated with AGI, and perioperative changes in abdominal morphology anthropometrics in pediatric cardiac surgery patients. 2.5. Statistical Analysis Statistical analysis was performed using IBM SPSS Statistics version 26.0. Continuous variables were expressed as a median and interquartile range (IQR) or as absolute numbers with percentages. The Mann–Whitney test and Fisher’s exact test were used to compare the difference of two groups. Binary logistic regression assessed the relationship between clinical risk factors and AGI, with results shown as odds ratios (OR) and 95% confidence intervals (CI). Variables with P < 0.10 in univariable analysis were further included in multivariable logistic regression. Values of P less than 0.05 were considered statistically significant. 3. Results The flow chart for this study is shown in Figure 1. A total of 137 pediatric patients underwent heart surgery with CPB from April 2021 and December 2021 were eventually analyzed in this study. The clinical characteristics and surgery-related information are summarized in Table 1. The median age and weight of pediatrics were 20 (IQR:6, 43) months and 10 (IQR:6.7, 14.25) kg, respectively. The majority of surgery were RACHS-1 II (n=97, 97/137, 70.8%). Figure 1 The flow chart for this study Table 1 Clinical characteristics and surgery-related information of included patients Variables (n = 137) Age, month 20.0 (6.0-43.0) Weight, kg 10.0 (6.7-14.3) Sex (male) Cyanotic disease Single ventricle Preoperative mechanical ventilation Preoperative Vasoconstricting drug use 68 (49.6) 47 (34.3) 1 (0.73) 0 0 RACHS-1 RACHS-1 II RACHS-1 III RACHS-1 IV Cross clamp duration, min CPB time, min 97 (70.8) 39 (28.5) 1 (0.7) 64.0 (41.5-93.0) 108.0 (79.0-167.0) Data are presented as median (IQR) for continuous variables, and n (%) for categorical variables. RACHS-I, the risk adjustment in congenital heart surgery-I; CPB, cardiopulmonary bypass. 3.1. The occurrence and characteristics of AGI after pediatric cardiac surgery Near half of the patients (n=60, 60/137, 43.79%) developed postoperative AGI. The grade I-IV of AGI were 20%, 71.67%, 5% and 3.33%, respectively. Mostly AGI occurred within 1-3 (median 1.6day (IQR:0.7-3.0) ) days after cardiac surgery.The characteristics and major symptoms of AGI were shown in Table 2. Table 2 Details of postoperative AGI AGI Grade Characteristics and major symptoms Patients n, (%) I Vomiting 9 (15.0) Absence of bowel sounds 3 (5.0) II IAH grade I with vomiting 1 (1.67) IAH grade I with absence of bowel sounds 17 (28.33) IAH grade I with diarrhoea 8 (13.33) IAH grade I with feeding intolerance 3 (5.0) IAH grade I with gastric residuals 1 (1.67) IAH grade I with paralysis of the lower GI tract 10 (16.67) IAH grade I with blood in gastric content or stool 3 (5.0) III IAH grade II with absence of bowel sounds 2 (3.33) IAH grade II with paralysis of the lower GI tract 1 (1.67) IV IAH grade II with necrotizing enterocolitis 2 (3.33) AGI, acute gastrointestinal injury; GI, gastrointestinal; IAH, intra-abdominal pressure. 3.2. A GI associated with clinical outcomes of pediatric patients under cardiac surgery Patients with AGI requiring greater inotropic support ( VIS max ), longer mechanical ventilation duration, longer length of ICU/hospital stay (all P < 0.001) after surgery. In addition, the incidence of composite outcome, LCOS and postoperative infection events were all significantly more common in the AGI group (all P < 0.001). In terms of composite outcome, the incidence of death, renal insuffificiency, hepatic injury, lactic acidosis were higher in AGI group compared with non-AGI group (P＜0.05). None of the pediatric patients after surgery experienced cardiac arrest or required CPB support, and there was no difference in postoperative neurological complications between the two groups (Table 3). Table 3 Comparison of in-hospital outcome between AGI and non-AGI group Variables All patients (n=137) AGI group （n=60） Non-AGI group（n=77） P value Composite outcome 53（38.69） 37（61.67） 16（20.78） ＜0.001 Death 3（2.19） 3（5） 0 0.025 Cardiac arrest 0 0 0 — Circulatory support 0 0 0 — Renal insuffificiency 37 (27.01) 26(43.44) 11(14.28) ＜0.001 Hepatic injury 16 (11.68) 14 (23.33) 2 (2.59) 0.002 Lactic acidosis 14 (10.22) 11 (18.33) 3 (3.89) 0.006 LCOS 44 (32.12) 35 (58.33) 9 (11.69) ＜0.001 Neurological complications 5（3.64） 4（6.67） 1(1.29) 0.091 Postoperative infection 79（57.66） 44（73.33） 35 (45.4) ＜0.001 Ventilation time, h 22 (5-119) 108.5 (23.75-219.75) 6 (4-23.75) ＜0.001 ICU duration, day 6 (2.5-9) 9 (6-15.25) 3 (2-6.75) ＜0.001 Hospital stay, day 12 (8.5-20) 16 (12-28.75) 10 (7-14) ＜0.001 VIS 24hmax 6.9 (2-15) 13.75 (6.95-23.25) 5 (0.25-7) ＜0.001 Data are presented as median (IQR) for continuous variables, and n (%) for categorical variables. LCOS, low cardiac output syndrome; ICU, intensive care unit; VIS, vasoactive-inotropic score. The univariable analyses demonstrated that cyanotic disease (OR =2.516, 95% CI =1.217-5.202, P=0.013), longer cross clamp duration (OR =1.013, 95% CI =1.005-1.021, P=0.002), higher RACHS-I grade (OR =2.638, 95% CI =1.266-5.498, P=0.01), longer CPB time (OR =1.013, 95% CI =1.006-1.019, P＜0.001), longer mechanical ventilation duration (OR =1.006, 95% CI =1.002-1.010, P =0.001), higher VIS 24hmax (OR =1.091, 95% CI =1.047-1.138, P＜0.001), postoperative LCOS (OR =4.256, 95% CI =1.988-9.111, P＜0.001), postoperative AGI (OR =6.133, 95% CI =2.875-13.083, P＜0.001) and postoperative infection (OR =3.550, 95% CI =1.663-7.581, P=0.001), as potential risk factors for postoperative composite outcome (Table 4). On further multivariate logistic regression analysis (Table 4), only AGI was significantly associated with postoperative composite outcome (OR =3.437, 95% CI =1.275-9.266, P=0.015). Table 4 Univariable and multivariable logistic regression on predictors associated with composite outcome Variables Univariable Multivariable OR OR 95%CI P-value OR OR 95%CI P-value Age, month 0.991 0.980, 1.002 0.107 — — — Weight, kg 0.952 0.904, 1.002 0.061 — — — Sex (male) 1.394 0.699, 2.780 0.345 — — — Cyanotic disease 2.516 1.217, 5.202 0.013 0.873 0.312, 2.443 0.796 Cross clamp duration, min 1.013 1.005, 1.021 0.002 1.006 0.993, 1.020 0.333 RACHS-1 2.638 1.266, 5.498 0.010 0.935 0.349, 2.500 0.893 CPB time, min 1.013 1.006, 1.019 ＜0.001 1.003 0.993, 1.013 0.516 Ventilation time, h 1.006 1.002, 1.010 0.001 1.001 0.999, 1.004 0.364 VIS 24hmax 1.091 1.047, 1.138 ＜0.001 1.052 0.994, 1.114 0.078 LCOS 4.256 1.988, 9.111 ＜0.001 0.661 0.185, 2.369 0.525 AGI 6.133 2.875, 13.083 ＜0.001 3.437 1.275, 9.266 0.015 Infection events 3.550 1.663, 7.581 0.001 2.259 0.922, 5.338 0.075 RACHS-1, the risk adjustment in congenital heart surgery-1; LCOS, low cardiac output syndrome; AGI, acute gastrointestinal injury; VIS, vasoactive-inotropic score; CPB, cardiopulmonary bypass time. 3.3. Predictors for the AGI The univariable logistic regression model showed that male (OR =2.109, 95% CI =1.061-4.194, P=0.033), cyanotic disease (OR =2.671, 95% CI =1.294-5.515, P=0.008), longer cross clamp duration (OR =1.011, 95% CI =1.003-1.019, P=0.005), higher RACHS-I grade (OR =3.433, 95% CI =1.608-7.327, P=0.001), higher preoperative IAH (OR =1.332, 95% CI =1.007-1.761, P=0.045), longer CPB time (OR =1.014, 95% CI =1.007-1.020, P＜0.001), higher level of intraoperative lactic acid (OR =1.317, 95%CI=1.070-1.620, P=0.009), and higher VIS 24hmax (OR =1.145, 95% CI =1.071-1.224, P＜0.001) were potential risk factors for postoperative AGI. The further multivariable analysis showed male (OR =2.520, 95% CI =1.093-5.810, P=0.030), longer CPB time(OR =1.012, 95% CI =1.003-1.021, P=0.007), and higher VIS 24hmax (OR =1.105, 95% CI =1.021-1.197, P=0.013) as an independent predictors of AGI (Table 5). Table 5 Univariable and multivariable logistic regression on predictors associated with AGI Univariable Multivariable Variables OR OR 95%CI P-value OR OR 95%CI P-value Age, month 0.991 0.981-1.002 0.095 — — — Weight, kg 0.943 0.896-0.993 0.027 0.927 0.867-0.991 0.027 Sex (male) 2.109 1.061-4.194 0.033 2.520 1.093-5.810 0.030 Cyanotic disease 2.671 1.294-5.515 0.008 0.691 0.262-1.822 0.455 Cross clamp duration, min 1.011 1.003-1.019 0.005 0.996 0.892-1.010 0.576 RACHS-1 3.433 1.608-7.327 0.001 1.860 0.667-5.183 0.235 Preoperative IAH, mmHg 1.332 1.007-1.761 0.045 1.285 0.922-1.792 0.139 CPB time, min 1.014 1.007-1.020 ＜0.001 1.012 1.003-1.021 0.007 Intraoperative lactic acid, mmol/L 1.317 1.070-1.620 0.009 0.881 0.707-1.096 0.255 VIS24hmax 1.145 1.071-1.224 ＜0.001 1.105 1.021-1.197 0.013 RACHS-1, The risk adjustment in congenital heart surgery-1; VIS, Vasoactive-Inotropic Score; CPB, cardiopulmonary bypass; IAH, intra-abdominal pressure. 3.4. Pre- and Post-operative anthropometric measurements of abdominal morphology As shown in Table 6, the anthropometric measurements of abdominal morphology including Sagittal abdominal diameter/Transverse abdominal diameter, AVI, and AP significantly increased immediately after surgery. Of those changes, Sagittal abdominal diameter /Transverse abdominal diameter at ICU admission vs. baseline as [0.641(0.590,0.682) vs. 0.615(0.561,0.670), p＜0.001], AVI at ICU admission vs. baseline as [3.213(2.469,3.873) vs. 2.976(2.350,3.748), p＜0.001], AP at ICU admission vs. baseline as [40.7(37.0,44.8) vs. 40.5(36.0,44.0), p＜0.001]. Also, the changes of anthropometric measurements of abdominal morphology were more obvious in the AGI group within 24 hours after surgery (Table 7). Table 6 Perioperative anthropometric measurements of abdominal morphology Variables Baseline ICU admission P value ICU 12hr P value ICU 24hrs P value AP, mm 40.5 (36.0,44.0) 40.7 (37.0,44.8) ＜0.001 40.8 (36.7,45.4) ＜0.001 40.0 (37.1,44.7) ＜0.001 Sagittal abdominal diameter/Transverse abdominal diameter 0.615 (0.56,0.67) 0.641 (0.59,0.68) ＜0.001 0.651 (0.60,0.70) ＜0.001 0.654 (0.60,0.70) 0.002 AVI 2.976 (2.35,3.75) 3.213 (2.47,3.87) ＜0.001 3.115 (2.49,3.98) ＜0.001 2.873 (2.49,3.689) ＜0.001 IAP, mmHg 2 (2,4) 7 (5,8) ＜0.001 6 (5,9) ＜0.001 7 (5,9) ＜0.001 Small bowel lumen size, cm 1.68 (1.22,2.05) 2.32 (1.64,2.80) ＜0.001 2.15 (1.65,2.72) ＜0.001 1.91 (1.48,2.65) ＜0.001 Large bowel lumen size, cm 2.12 (1.50,2.62) 2.86 (2.06,3.31) ＜0.001 2.62 (1.98,3.16) ＜0.001 2.35 (1.73,3.02) ＜0.001 Ascites 0 16 27 30 Data are presented as median (IQR) for continuous variables, and n (%) for categorical variables. AP, abdominal perimeter; AVI, abdominal volume index; IAP, intra-abdominal pressure. Table 7 Abdominal Parameters and Pressure between Patients with or without AGI at ICU admission,12hrs,24hrs. Variables Patients with AGI (n=60) Patients without AGI (n=77) P value The rate of AP change ICU admission/Baseline ICU 12hrs/Baseline ICU 24hrs/Baseline 1.032 (1.001,1.064) 1.036 (1.006,1.083) 1.055 (1.013,1.082) 1.006 (0.997,1.029) 1.004 (0.988,1.054) 1.016 (0.988,1.054) ＜0.001 ＜0.001 ＜0.001 Sagittal abdominal diameter/Transverse abdominal diameter ICU admission/Baseline ICU 12hrs/Baseline ICU 24hrs/Baseline 0.672 (0.627,0.714) 0.669 (0.631,0.723) 0.669 (0.613,0.712) 0.629 (0.588,0.672) 0.624 (0.588,0.672) 0.628 (0.687,0.669) ＜0.001 ＜0.001 0.009 The rate of AVI change ICU admission/Baseline ICU 12hrs/Baseline ICU 24hrs/Baseline 1.047 (1.010,1.135) 1.098 (1.008,1.175) 1.086 (1.015,1.177) 1.033 (0.996,1.060) 1.038 (1.001,1.098) 1.066 (1.004,1.107) 0.010 0.008 0.157 The rate of small bowel lumen size change ICU admission/Baseline ICU 12hrs/Baseline ICU 24hrs/Baseline 1.321 (1.252,1.514) 1.336 (1.235,1.604) 1.287 (1.204,1.517) 1.308 (1.194,1.503) 1.274 (1.148,1.533) 1.211 (1.092,1.374) 0.283 0.023 0.061 The rate of large bowel lumen size change ICU admission/Baseline ICU 12hrs/Baseline ICU 24hrs/Baseline 1.249 (1.171,1.456) 1.186 (1.104,1.387) 1.183 (1.076,1.355) 1.301 (1.207,1.371) 1.244 (1.123,1.382) 1.181 (1.049,1.336) 0.404 0.740 0.779 Ascites ICU admission/Baseline ICU 12hrs/Baseline ICU 24hrs/Baseline 13 (13/16) 18 (18/27) 21 (21/30) 3 (3/16) 9 (9/27) 9 (9/30) 0.001 ＜0.001 ＜0.001 AP, abdominal perimeter; AVI, abdominal volume index; IAP, intra-abdominal pressure; ICU, intensive care unit. 3.5. Pre- and Post-operative abdominal contents Small and large bowel lumen size measured by abdominal ultrasound significantly increased immediately after surgery [Small bowel lumen size ICU admission vs. baseline as [2.32 (1.64,2.80) vs. 1.68 (1.22,2.05), p＜0.001]; Large bowel lumen size ICU admission vs. baseline as [2.86 (2.06,3.31) vs. 2.12 (1.50,2.62), p＜0.001] almostly remained dilatable within the first 24 hours in ICU. But in addition to the ratio of small bowel diameter at ICU 12 hrs, we observed no significant difference between AGI and non-AGI groups in the ratio of small and large bowel diameter (Table 7). However, 30 patients (21.89%) had ascites within 24 hours after surgery revealed by abdominal ultrasound (Table 6). The incidence of ascites in AGI patients (35%) was 3 times more than that in non-AGI patients (11.68%) (Table 7). 4. Discussion The study presents the first preliminary clinical investigation of AGI following pediatric cardiac surgery. Our findings highlight three key observations: (1) AGI is a relatively common complication in pediatric cardiac surgery with CPB and contributed to adverse clinical outcomes; (2) The occurrence of AGI is potentially driven by several modifiable factors during cardiac surgery; and (3) early anthropometric measurements of abdominal morphology may serve as a predictive indicator for severe AGI. This study found that the incidence of AGI was 43.79%, significantly lower than the 67.3% incidence reported in adult cardiac surgery patients [ 13 ] but within the range reported in other critically ill children (14.1%-58.5%) [ 14 – 15 ] . We found that AGI was significantly associated with adverse outcomes in pediatric cardiac surgery patients, aligning with prior evidence linking AGI to poor prognosis in both adult cardiac surgery [ 21 ] and critically ill pediatric populations [ 14 ] . Importantly, our study also revealed AGI as an independent risk factor for composite outcome.Clinicians should attach great importance to the occurrence of AGI after cardiac surgery. Our study identified the longer CPB time as independent perioperative risk factor for the development of AGI. Yang and colleagues [ 21 ] reported that CPB duration ≥ 132 min as independent risk factor for AGI in patients undergoing heart valve replacement. The mechanisms underlying CPB-induced AGI encompass a multifaceted pathway.During CPB, the gastrointestinal tract underwent hypoxia, hypoperfusion, and stress. Combined with ischemia-reperfusion injury, systemic inflammation, and perioperative vasoactive drug use, these factors collectively leaded to intestinal epithelial damage, barrier dysfunction, and increased permeability, culminating in gastrointestinal injury [ 22 – 23 ] . Our study also demonstrated that high-dose vasoactive drugs contributed to the occurrence of AGI following cardiac surgery.We hypothesize that excessive vasoactive drugs may cause significant vasoconstriction in the gastrointestinal tract, leading to reduced perfusion and thereby increasing the risk of AGI. This speculation was supported by evidence demonstrating that abdominal visceral organ function and blood perfusion were served as reliable indicators for evaluating gastrointestinal function [ 24 ] . IAH serves as a diagnostic criterion for AGI.The previous study suggested that peritoneal-to-abdominal height ratio (PAR) ≥ 0.52 and the ratio of maximal anteroposterior to transverse abdominal diameter > 0.8 could help clinicians to identify IAH on abdominal computed tomography (CT) scan [ 25 ] . The underlying mechanism might involved increased intra-abdominal content elevating IAP and altering abdominal compliance, triggering sequential abdominal remodeling, stretching, and compression.This resulted in distinct morphological changes (elliptical→ellipsoidal→spherical) [ 18 ] . Although the pediatric abdominal wall possesses distinct characteristic,such as reduced thickness, greater pliability, underdeveloped musculature and connective tissue, which can confer greater compliance and an enhanced capacity to accommodate elevations in IAP. Notably, our study found that all pediatric patients undergoing cardiac surgery exhibited immediate postoperative increases in intra-abdominal content(including bowel content and ascites detected by ultrasound), leading to elevated IAP and subsequent abdominal morphological changes (increased sagittal abdominal diameter/transverse abdominal diameter, AVI, and AP). These alterations were significantly more obvious in patients who developed AGI. Morever, Gao et al. developed an AGI ultrasound (AGIUS) score incorporating bowel diameter, wall thickness, and peristalsis, demonstrating a positive correlation with gastrointestinal injury in critically ill patients [ 26 ] . Gastrointestinal ultrasound represents a non-invasive monitoring tool. Our study observed that pediatric patients undergoing cardiac surgery exhibited varying degrees of intestinal dilation postoperatively, suggesting that GIUS may have significant promise for assessing AGI in this population. However, its clinical application is currently limited by the lack of age-specific reference ranges for intestinal parameters during developmental stages. Our work addressed a critical gap by establishing a significant link between early alterations in abdominal anthropometry and the development of AGI in pediatric patients after cardiac surgery. This study has several limitations. First, the single-center design with a relatively small sample size (n = 137) may restrict the generalizability of the findings. Second, the diagnosis of AGI was subjective, and the majority of patients required postoperative mechanical ventilation, which may have resulted in an underestimation of the true AGI incidence. Third, the ultrasound-based measurement of intestinal diameter was subjective and could be affected by abdominal distension. Finally, dynamic changes in intra-abdominal organ volumes were not evaluated. 5. Conclusion Postoperative AGI is a common complication in pediatric cardiac surgery and is associated with adverse outcomes. Prolonged CPB and high-dose vasoactive drugs may predict AGI. Early postoperative changes in abdominal anthropometric measurements could serve as an early warning indicator. Declarations Declaration of competing interest The authors have no conflicts of interest or disclosures to report. Ethics approval and consent to participate The used data were publicly available and approved by their corresponding institutions. The study protocol was approved by The Biomedical Research Ethics Committee of West China Hospital of Sichuan University (Approval number 2020(1227)) on February 25, 2021 and was registered ( https://www.chictr.org.cn , registration number: ChiCTR2100044840) before participants enrollment. Funding This study did not receive any commercial sponsorship. Author Contribution All authors have made substantial and intellectual contributions to the work and approved the submitted article. Lijing Deng conceived and designed this study. Data collection, analyses, interpretation and visualisation were performed by Shouping Wang, Wang Niu, and Jiarong Zeng. The manuscript was written by Shouping Wang, Wang Niu, and Lijing Deng revised it critically for important intellectual content. All authors confirm that they had full access to all the data in the study and accept the responsibility to submit for publication. Shouping Wang and Wang Niu contributed equally to this work, and list as co-first author. Data Availability Data from the present study was available to all researchers upon application. The detailed information and codes required to reanalyze the data in this work are available from the corresponding author (Lijing Deng) upon reasonable request. References Dolk H, Loane M, Garne E, for the European Surveillance of Congenital Anomalies (EUROCAT) Working Group. Congenital heart defects in Europe: prevalence and perinatal mortality, 2000 to 2005. Circulation. 2011;123:841–9. van der Linde D, Konings EE, Slager MA et al. Birth prevalence of congenital heart disease worldwide: a systematic review and meta-analysis. J Am Coll Cardiol,2011,58:2241–7. Mason CA, Kirby RS, Sever LE, et al. Prevalence is the preferred measure of frequency of birth defects. Birth Defects Res Clin Mol Teratol. 2005;73:690–2. Bernier PL, Stefanescu A, Samoukovic G, et al. The challenge of congenital heart disease worldwide: epidemiologic and demographic facts. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2010;13:26–34. Dahlawi N, Milnes LJ, Swallow V. Behaviour and emotions of children and young people with congenital heart disease: A literature review. J Child Health Care 2020,24(2):317–32. Liamlahi R, Latal B. Neurodevelopmental outcome of children with congenital heart disease. Handb Clin Neurol. 2019;162:329–45. Biber S, Andonian C, Beckmann J et al. Current research status on the psychological situation of parents of children with congenital heart disease. Cardiovasc Diagn Ther 2019,9(Suppl 2):S369–76. David G, Sinclair MB, Patricia L et al. The effect of cardiopulmonary bypass on intestinal and pulmonary endothelial permeability.Chest,1995,108(3):718–24. Bronicki RA, Hall M. Cardiopulmonary Bypass-Induced Inflammatory Response: Pathophysiology and Treatment.Pediatr Crit Care Med,2016,17(8 Suppl 1):S272–8. Ohri SK, Velissaris T. Gastrointestinal dysfunction following cardiac surgery. Perfusion. 2006;21:215–23. Meng M, Klingensmith NJ, Coopersmith CM. New insights into the gut as the driver of critical illness and organ failure. Curr Opin Crit Care. 2017;23(2):143–8. Blaser AR, Malbrain MLNG, Starkopf J, et al. Gastrointestinal function in intensive care patients: terminology, defifinitions and management. Recommendations of the ESICM Working Group on Abdominal Problems. Intensive Care Med. 2012;38:384–94. Seilitz J, Edström M, Sköldberg M, et al. Early Onset of Postoperative Gastrointestinal Dysfunction Is Associated With Unfavorable Outcome in Cardiac Surgery: A Prospective Observational Study. J Intensive Care Med. 2021;36(11):1264–71. Zhang D, Li Y, Ding L, et al. Prevalence and outcome of acute gastrointestinal injury in critically ill patients: A systematic review and meta-analysis. Med (Baltim). 2018;97(43):e12970. Fu W, Shi N, Wan Y et al. Risk Factors of Acute Gastrointestinal Failure in Critically Ill Patients With Traumatic Brain Injury. J Craniofac Surg 2020 Mar/Apr;31(2):e176–9. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191–4. Kirkpatrick AW, Roberts DJ, De Waele J, et al. Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med. 2013;39:1190–206. Manu LNGM, Derek JR, Inneke Dl et al. The role of abdominal compliance, the neglected parameter in critically ill patients - A consensus review of 16. Part 2: Measurement techniques and management recommendations. Anaesthesiol Intensive Therapy 2014, (46)406–32. Malbrain ML, De laet I, Regenmortel NV, et al. Can the abdominal perimeter be used as an accurate estimation of intra-abdominal pressure? Crit Care Med. 2009;37(1):316–23. Butts RJ, Scheurer MA, Zyblewski SC, et al. A composite outcome for neonatal cardiac surgery research. J Thorac Cardiovasc Surg. 2014;147:428–33. Yang X, Liu R, An Z, et al. Probiotic mitigates gut hypoperfusion-associated acute gastrointestinal injury in patients undergoing cardiopulmonary bypass: a randomized controlled trial. BMC Med. 2025;23(1):238. Viana FF, Chen Y, Almeida AA, Baxter HD, Cochrane AD, Smith JA. Gastrointestinal complications after cardiac surgery: 10-year experience of a single Australian centre. ANZ J Surg. 2013;83(9):651-6. 10.1111/ans.12134 . Epub 2013 Mar 26. PMID: 23530720. Pathan N, Burmester M, Adamovic T, Berk M, Ng KW, Betts H, Macrae D, Waddell S, Paul-Clark M, Nuamah R, Mein C, Levin M, Montana G, Mitchell JA. Intestinal injury and endotoxemia in children undergoing surgery for congenital heart disease. Am J Respir Crit Care Med. 2011;184(11):1261–9. 10.1164/rccm.201104-0715OC . Epub 2011 Aug 25. PMID: 21868501. Yue C, Su L, Wang J, Cui N, Zhou Y, Cheng W, Tang B, Rui X, He H, Long Y. Prediction of mechanical ventilation outcome by early abdominal-visceral-blood-flow-and-function score in critically ill patients after cardiopulmonary bypass in the ICU: A prospective observational study. J Intensive Med. 2023;4(1):101–7. PMID: 38263967; PMCID: PMC10800766. Bouveresse S, Piton G, Badet N, Besch G, Pili-Floury S, Delabrousse E. Abdominal compartment syndrome and intra-abdominal hypertension in critically ill patients: diagnostic value of computed tomography. Eur Radiol. 2019;29(7):3839–46. 10.1007/s00330-018-5994-x . Epub 2019 Feb 8. PMID: 30737569. Gao T, Cheng MH, Xi FC, Chen Y, Cao C, Su T, Li WQ, Yu WK. Predictive value of transabdominal intestinal sonography in critically ill patients: a prospective observational study. Crit Care. 2019;23(1):378. 10.1186/s13054-019-2645-9 . PMID: 31775838; PMCID: PMC6880579. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 04 Feb, 2026 Reviews received at journal 02 Feb, 2026 Reviews received at journal 01 Feb, 2026 Reviewers agreed at journal 26 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviewers invited by journal 14 Jan, 2026 Editor invited by journal 17 Dec, 2025 Editor assigned by journal 17 Dec, 2025 Submission checks completed at journal 17 Dec, 2025 First submitted to journal 16 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8372476","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":576147287,"identity":"fda360ea-df38-4a6e-8016-7b95d04e1640","order_by":0,"name":"Shouping Wang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Shouping","middleName":"","lastName":"Wang","suffix":""},{"id":576147290,"identity":"ff09cdee-c6d6-433c-850a-908eb7182141","order_by":1,"name":"Wang Niu","email":"","orcid":"","institution":"West China Hospital of Sichuan 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1","display":"","copyAsset":false,"role":"figure","size":87081,"visible":true,"origin":"","legend":"\u003cp\u003eThe flow chart for this study\u003c/p\u003e","description":"","filename":"Theflowchartforthisstudy.png","url":"https://assets-eu.researchsquare.com/files/rs-8372476/v1/75f1c38e77c947407f723ca7.png"},{"id":100665952,"identity":"08c65108-31cc-4e9b-ae81-1d82bb99916a","added_by":"auto","created_at":"2026-01-20 09:32:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1148518,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8372476/v1/b524360d-3179-4d40-a51b-0832b1426cdf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Acute gastrointestinal injury after pediatric cardiac surgery: A single-center prospective observational study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eCongenital heart disease (CHD) accounts for approximately 28% of all congenital anomalies \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e, with a global prevalence of 8 per 1000 live births \u003csup\u003e[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. CHD significantly impacts \u0026zwnj;the survival, neurodevelopment and overall quality of life on affected children \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e,\u0026zwnj;while also imposing substantial physical and psychological burdens on their parents\u0026zwnj; \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSurgical correction with CPB represents the primary therapeutic approach for pediatric patients with severe forms of CHD. During CPB, the gastrointestinal tract is highly susceptible to damage due to factors such as hypoxia, hypoperfusion, stress, ischemia-reperfusion injury, and systemic inflammatory response \u003csup\u003e[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Over the past three decades, the gastrointestinal tract has been increasingly recognized as a pivotal \"engine\" driving multiple organ dysfunction in critical ill patients \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. In 2012, the European Society of Intensive Care Medicine (ESICM) established a standardized four-grade classification system for AGI identification in critically ill patients \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. This grading system, where higher grades reflect more severe gastrointestinal damage and worse clinical outcomes, has been widely adopted in clinical practice.\u003c/p\u003e \u003cp\u003eWith a reported incidence of 67.3% \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e, AGI is a common complication in adult cardiac surgery patients, and its pathogenesis involves a spectrum of risk factors \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. However, AGI remains understudied in pediatric population, and its risk factors remain unclear. This prospective observational study aims to: (1) investigate the incidence and prognostic influence of AGI, and (2) identify the risk factors and clinical characteristics associated with AGI in pediatric patients undergoing open-heart surgery with CPB.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study design\u003c/h2\u003e \u003cp\u003e This prospective single-center observational study received approval from the Biomedical Research Ethics Committee of West China Hospital, Sichuan University (Approval No. 2020(1227)) on February 25, 2021. The trial was registered at the Chinese Clinical Trial Registry (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.chictr.org.cn\u003c/span\u003e\u003cspan address=\"https://www.chictr.org.cn\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, Registration No. ChiCTR2100044840) before participant enrollment. Written informed consent was obtained from all legal guardians of pediatric participants before inclusion. Data and safety were monitored at regular 3-month intervals. The study adhered to the principles of the World Medical Association's Declaration of Helsinki and followed Good Clinical Practice standards \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePediatric patients (\u0026lt;\u0026thinsp;14 years) undergoing selective open-heart surgery with CPB were eligible for participation. Children with preoperative gastrointestinal disorders were excluded. Patients were divided into AGI or non-AGI groups based on criteria defined by the European Society of Intensive Care Medicine \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Study Procedures\u003c/h2\u003e \u003cp\u003eScreening for eligibility was completed before the clinical evaluation. The following data were monitored and recorded: demographics, operation-related information, postoperative digestive symptoms, intra-abdominal pressure (IAP), abdominal diameter, ultrasonic measurement of intestinal diameter and postoperative complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Assessed variables\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1. Monitoring and evaluation of gastrointestinal function\u003c/h2\u003e \u003cp\u003eLongitudinal monitoring of gastrointestinal symptoms and signs was performed by trained clinicians, with assessments commencing upon ICU admission and continuing for the subsequent 3 days. Researchers investigated cases of AGI based on the clinical characteristics and examination results. The electronic medical record system was also reviewed to ensure that important gastrointestinal symptoms and signs were not missed.\u003c/p\u003e \u003cp\u003eAccording to the European Society of Critical Care Medicine \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e, postoperative conditions which manifested as vomiting, diarrhoea, feeding intolerance, gastric residuals, gastrointestinal bleeding, absent peristalsis, paralysis of lower gastrointestinal tract, necrotizing enterocolitis and intra-abdominal hypertension were considered AGI. Of these gastrointestinal conditions, vomiting was defined as \u0026ldquo;the occurrence of any visible regurgitation of gastric content irrespective of the amount\u0026rdquo;. Diarrhoea was defined as \u0026ldquo;stool property changed, such as sparse stool and watery stool\u0026rdquo;. Feeding intolerance was defined as \u0026ldquo;digestive disorder after enteral feeding, which leads to abdominal distension, vomiting, gastric retention\u0026rdquo;. Gastric residuals was defined as \u0026ldquo;the gastric remnant is greater than 50% of the previous feeding amount\u0026rdquo;. GI bleeding was defined as \u0026ldquo;any bleeding into the GI tract lumen, confirmed by macroscopic presence of blood in vomited fluids, gastric aspirate or stool\u0026rdquo;. Absent peristalsis was defined as \u0026ldquo;no bowel sounds are heard at cautious auscultation\u0026rdquo;. Paralysis of lower GI tract was defined as \u0026ldquo;the inability of the bowel to pass stool due to impaired peristalsis. Necrotizing enterocolitis (NEC) was defined as \u0026ldquo;an acute reduction in the supply of oxygenated blood to the small intestine or large intestine, typically resulting in acidosis, abdominal distention, pneumatosis, and/or intestinal perforation, that prompts initiation of antibiotics or exploratory laparotomy\u0026rdquo;. Intra-abdominal hypertension (IAH) was defined as \u0026ldquo;a persistent or repeated increase in IAP greater than 10mmHg\u0026rdquo; \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. The severity and diagnostic criteria of AGI:\u0026zwnj; Grade I, increased risk of gastrointestinal dysfunction(self-limiting); Grade II, gastrointestinal dysfunction requiring intervention; \u0026zwnj;Grade III\u0026zwnj;, gastrointestinal failure unresponsive to treatment; \u0026zwnj;Grade IV, life-threatening gastrointestinal failure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2. The measurement of intra-abdominal pressure\u003c/h2\u003e \u003cp\u003eIAP was measured by trained nursing staff according to a standardized protocol \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e via a commercially available pressure transducer (DPT-248, China). Measurements were obtained at the time of admission, and 12h, 24h thereafter. IAP was measured in mmHg via a urinary catheter connected to a standard invasive pressure monitoring system with a three-way stopcock. With the patient in complete supine position, the transducer was zeroed at the level of the mid-axillary line and the iliac crest. After ensuring the absence of abdominal muscle contraction, the bladder was instilled with 1 mL/kg of sterile saline (range of 3\u0026thinsp;~\u0026thinsp;25 mL). Following a 30\u0026thinsp;~\u0026thinsp;60 seconds stabilization period at end-expiration, the IAP value was recorded from the bedside monitor.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.3.3. The enteral feeding practice\u003c/h2\u003e \u003cp\u003eAfter transfered to the ICU, enteral nutrition (EN) was initiated in all patients while achieving hemodynamic stability, defined as the absence of exacerbated vasopressor support, low cardiac output, or evidence of oxygen supply-demand imbalance. EN was commenced at a trophic rate of 16 mL/kg/day and advanced gradually according to tolerance. The gastric tube was removed following extubation once the patient's ability for adequate oral intake was confirmed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.3.4. The anthropometric measurements of abdominal morphology\u003c/h2\u003e \u003cp\u003eTrained physicians evaluated the anthropometric measurements of abdominal morphology which used in several previous studies \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Abdominal perimeter (AP) is the abdominal circumference at its largest point (usually at the level of the umbilicus). Hip circumference is the largest horizontal girth between waist and thigh. Waist circumference is the smallest horizontal girth between the rib cage and iliac crest. Sagittal abdominal diameter or abdominal short axis is the height between the table or bed and the apex of the abdomen, while the transverse abdominal diameter or abdominal long axis is the distance between the both sides of abdominal walls perpendicular to the horizontal plane of the sagittal abdominal diameter or abdominal short axis), and finally calculated abdominal volume index (AVI, caculated as [2 \u0026times; [Waist]\u003csup\u003e2\u003c/sup\u003e + 0.7 \u0026times; ([Waist]\u0026ndash;[Hip])\u003csup\u003e2\u003c/sup\u003e]/1000.\u003c/p\u003e \u003cp\u003eNursing staff recorded these anthropometric data at patients admission and 12-hour intervals thereafter using soft rulers and vernier calipers. Meanwhile, physicians performed abdominal ultrasound (Mindray, 35C50EB, 5.0-7.5 MHz convex transducer) to measure intestinal diameters. Jejunal diameter was assessed 1 cm distal to the Treitz ligament, and ascending colon diameter was measured 1 cm proximal to the ileocecal valve. The convex probe was placed in the left upper abdomen for clockwise scanning, with optional 90\u0026deg;rotation for enhanced horizontal sliding to visualize the jejunum. For colonic assessment, longitudinal scanning along the descending colon was performed.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Investigator training, data collection, and outcome measures\u003c/h2\u003e \u003cp\u003ePrior to trial initiation, investigators (Shouping Wang, Wang Niu) responsible for data collection and follow-up assessments received standardized training from the principal investigator (Lijing Deng) on assessment protocols, including AGI definition evaluation and postoperative composite outcome assessment. Baseline data collected included demographics, IAP, abdominal morphology anthropometrics, and intestinal diameters. Intraoperative data encompassed extracorporeal circulation duration and vasoactive-inotropic score (VIS), calculated as:VIS\u0026thinsp;=\u0026thinsp;Dopamine\u0026thinsp;+\u0026thinsp;Dobutamine\u0026thinsp;+\u0026thinsp;10\u0026times;Milrinone\u0026thinsp;+\u0026thinsp;100\u0026times;Adrenaline\u0026thinsp;+\u0026thinsp;100\u0026times;Norepinephrine\u0026thinsp;+\u0026thinsp;10,000\u0026times;Pituitrin (all in ug/kg/min)\u0026zwnj;.The study utilized intraoperative VIS\u003csub\u003emax\u003c/sub\u003e and postoperative VIS\u003csub\u003e24hmax\u003c/sub\u003e to quantify vasoactive drug intensity.Postoperative monitoring included GI symptoms and in-hospital composite outcome \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e, defined as any of death, cardiac arrest, ECMO, hepatic/renal insufficiency, or lactic acidosis. Additional recorded outcomes comprised low cardiac output syndrome (LCOS), infections, and neurological complications.\u003c/p\u003e \u003cp\u003ePrimary outcomes\u0026zwnj; focused on postoperative AGI incidence and its prognostic influence on clinical outcomes. Secondary outcomes\u0026zwnj; identified the risk factors and clinical characteristics associated with AGI, and perioperative changes in abdominal morphology anthropometrics in pediatric cardiac surgery patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Statistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using IBM SPSS Statistics version 26.0. Continuous variables were expressed as a median and interquartile range (IQR) or as absolute numbers with percentages. The Mann\u0026ndash;Whitney test and Fisher\u0026rsquo;s exact test were used to compare the difference of two groups. Binary logistic regression assessed the relationship between clinical risk factors and AGI, with results shown as odds ratios (OR) and 95% confidence intervals (CI). Variables with P\u0026thinsp;\u0026lt;\u0026thinsp;0.10 in univariable analysis were further included in multivariable logistic regression. Values of P less than 0.05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe flow chart for this study is shown in Figure 1.\u0026nbsp;A total of 137 pediatric patients underwent heart surgery with CPB from April 2021\u0026nbsp;and December 2021 were eventually analyzed in this study.\u0026nbsp;The clinical characteristics and surgery-related information are summarized in Table 1.\u0026nbsp;The median age and weight of pediatrics were 20 (IQR:6, 43) months and 10 (IQR:6.7, 14.25) kg, respectively. The majority of surgery were RACHS-1 II (n=97, 97/137, 70.8%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe flow chart for this study\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical characteristics and surgery-related information of included patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"404\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e(n = 137)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003eAge, month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e20.0 (6.0-43.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003eWeight, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e10.0 (6.7-14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003eSex (male)\u003c/p\u003e\n \u003cp\u003eCyanotic disease\u003c/p\u003e\n \u003cp\u003eSingle ventricle\u003c/p\u003e\n \u003cp\u003ePreoperative mechanical ventilation\u003c/p\u003e\n \u003cp\u003ePreoperative Vasoconstricting drug use\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e68 (49.6)\u003c/p\u003e\n \u003cp\u003e47 (34.3)\u003c/p\u003e\n \u003cp\u003e1 (0.73)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 253px;\"\u003e\n \u003cp\u003eRACHS-1\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRACHS-1 II\u003c/p\u003e\n \u003cp\u003eRACHS-1 III\u003c/p\u003e\n \u003cp\u003eRACHS-1 IV\u003c/p\u003e\n \u003cp\u003eCross clamp duration, min\u003c/p\u003e\n \u003cp\u003eCPB time, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e97 (70.8)\u003c/p\u003e\n \u003cp\u003e39 (28.5)\u003c/p\u003e\n \u003cp\u003e1 (0.7)\u003c/p\u003e\n \u003cp\u003e64.0 (41.5-93.0)\u003c/p\u003e\n \u003cp\u003e108.0 (79.0-167.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as median (IQR)\u0026nbsp;for continuous variables, and n (%) for categorical variables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRACHS-I, the risk adjustment in congenital heart surgery-I; CPB, cardiopulmonary bypass.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.1. \u0026nbsp; The occurrence and characteristics of AGI after pediatric cardiac surgery\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNear half of the patients (n=60, 60/137, 43.79%) developed postoperative AGI. The grade I-IV of AGI were 20%, 71.67%, 5% and 3.33%, respectively. Mostly AGI occurred within 1-3 (median 1.6day (IQR:0.7-3.0) ) days after cardiac surgery.The characteristics and major symptoms of AGI were shown in Table 2. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDetails of postoperative AGI\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"584\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eAGI Grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eCharacteristics and major symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003ePatients \u0026nbsp;n, (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eVomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e9 (15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eAbsence of bowel sounds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eIAH grade I with vomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (1.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eIAH grade I with absence of bowel sounds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e17 (28.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eIAH grade I with diarrhoea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e8 (13.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eIAH grade I with feeding intolerance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eIAH grade I with gastric residuals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (1.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eIAH grade I with paralysis of the lower GI tract\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e10 (16.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eIAH grade I with blood in gastric content or stool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eIAH grade II with absence of bowel sounds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2 (3.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eIAH grade II with paralysis of the lower GI tract\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (1.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003eIAH grade II with necrotizing enterocolitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2 (3.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAGI,\u0026nbsp;acute gastrointestinal injury; GI, gastrointestinal; IAH, intra-abdominal pressure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.2. \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eA\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eGI associated with clinical outcomes of pediatric patients under cardiac surgery\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients with AGI requiring greater inotropic support ( VIS\u003csub\u003emax\u003c/sub\u003e), longer mechanical ventilation duration, longer length of ICU/hospital stay (all P \u0026lt; 0.001) after surgery. In addition, the incidence of composite outcome, LCOS and postoperative infection events were all significantly more common in the AGI group (all P \u0026lt; 0.001). In terms of composite outcome, the incidence of death, renal insuffificiency, hepatic injury, lactic acidosis were higher in AGI group compared with non-AGI group (P＜0.05). None of the pediatric patients after surgery experienced cardiac arrest or required CPB support, and there was no difference in postoperative neurological complications between the two groups (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComparison of in-hospital outcome between AGI and non-AGI group\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eAll patients\u003c/p\u003e\n \u003cp\u003e(n=137)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003eAGI group\u003c/p\u003e\n \u003cp\u003e（n=60）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eNon-AGI group（n=77）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eComposite outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e53（38.69）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e37（61.67）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e16（20.78）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3（2.19）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e3（5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eCardiac arrest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eCirculatory support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eRenal insuffificiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e37 (27.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e26(43.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e11(14.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eHepatic injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e16 (11.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e14 (23.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (2.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eLactic acidosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e14 (10.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e11 (18.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (3.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eLCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e44\u0026nbsp;(32.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e35\u0026nbsp;(58.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e9 (11.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eNeurological complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e5（3.64）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e4（6.67）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1(1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.091\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003ePostoperative infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e79（57.66）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e44（73.33）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e35 (45.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eVentilation time,\u0026nbsp;h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e22 (5-119)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e108.5 (23.75-219.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6\u0026nbsp;(4-23.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eICU duration,\u0026nbsp;day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e6 (2.5-9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e9 (6-15.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (2-6.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eHospital stay, day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e12 (8.5-20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e16 (12-28.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e10 (7-14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eVIS\u003csub\u003e24hmax\u0026nbsp;\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e6.9 (2-15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e13.75 (6.95-23.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5 (0.25-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eData are presented as median (IQR) for continuous variables, and n (%) for categorical variables.\u003c/p\u003e\n\u003cp\u003eLCOS,\u0026nbsp;low cardiac output syndrome; ICU, intensive care unit; VIS, vasoactive-inotropic score.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe univariable analyses demonstrated that cyanotic disease (OR =2.516, 95% CI =1.217-5.202, P=0.013), longer cross clamp duration (OR =1.013, 95% CI =1.005-1.021, P=0.002), higher RACHS-I grade (OR =2.638, 95% CI =1.266-5.498, P=0.01), longer CPB time (OR =1.013, 95% CI =1.006-1.019, P＜0.001), longer mechanical ventilation duration (OR =1.006, 95% CI =1.002-1.010, P\u0026nbsp;=0.001), higher VIS\u003csub\u003e24hmax\u003c/sub\u003e (OR =1.091, 95% CI =1.047-1.138, P＜0.001), postoperative LCOS (OR =4.256, 95% CI =1.988-9.111, P＜0.001), postoperative AGI (OR =6.133, 95% CI =2.875-13.083, P＜0.001) and postoperative infection (OR =3.550, 95% CI =1.663-7.581, P=0.001), as potential risk factors for postoperative composite outcome (Table 4). On\u0026nbsp;further\u0026nbsp;multivariate logistic regression analysis (Table 4),\u0026nbsp;only AGI was significantly associated with postoperative composite outcome (OR =3.437, 95% CI =1.275-9.266, P=0.015).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnivariable and multivariable logistic regression on predictors associated with composite outcome\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eUnivariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eMultivariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eOR 95%CI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eOR 95%CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eAge, month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.991\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e0.980, 1.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eWeight, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.952\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e0.904, 1.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eSex (male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1.394\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e0.699, 2.780\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.345\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eCyanotic disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e2.516\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1.217, 5.202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.873\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.312, 2.443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.796\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eCross clamp duration, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1.005, 1.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.993, 1.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.333\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eRACHS-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e2.638\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1.266, 5.498\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.935\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.349, 2.500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.893\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eCPB time, min\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1.006, 1.019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.993, 1.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.516\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eVentilation time, h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1.002, 1.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.999, 1.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.364\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eVIS\u003csub\u003e24hmax\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1.091\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1.047, 1.138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.994, 1.114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eLCOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e4.256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1.988, 9.111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.661\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.185, 2.369\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.525\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eAGI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e6.133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e2.875, 13.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e3.437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1.275, 9.266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eInfection events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3.550\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1.663, 7.581\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e2.259\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.922, 5.338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 158px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eRACHS-1, the risk adjustment in congenital heart surgery-1; LCOS, low cardiac output syndrome; AGI, acute gastrointestinal injury; VIS, vasoactive-inotropic score; CPB, cardiopulmonary bypass time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.3. \u0026nbsp; Predictors for the AGI\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe univariable logistic regression model showed that male\u0026nbsp;(OR =2.109, 95% CI =1.061-4.194, P=0.033),\u0026nbsp;cyanotic disease (OR =2.671, 95% CI =1.294-5.515, P=0.008), longer cross clamp duration (OR =1.011, 95% CI =1.003-1.019, P=0.005),\u0026nbsp;higher RACHS-I grade\u0026nbsp;(OR =3.433, 95% CI =1.608-7.327, P=0.001), higher\u0026nbsp;preoperative IAH (OR =1.332, 95% CI =1.007-1.761,\u0026nbsp;P=0.045), longer CPB time\u0026nbsp;(OR =1.014, 95% CI =1.007-1.020, P＜0.001), higher level of intraoperative lactic acid\u0026nbsp;(OR =1.317, 95%CI=1.070-1.620,\u0026nbsp;P=0.009), and higher VIS\u003csub\u003e24hmax\u003c/sub\u003e (OR =1.145, 95% CI =1.071-1.224, P＜0.001)\u0026nbsp;were\u0026nbsp;potential risk factors for\u0026nbsp;postoperative AGI. The further multivariable analysis showed male\u0026nbsp;(OR =2.520, 95% CI =1.093-5.810,\u0026nbsp;P=0.030), longer CPB time(OR =1.012, 95% CI =1.003-1.021,\u0026nbsp;P=0.007), and higher VIS\u003csub\u003e24hmax\u003c/sub\u003e (OR =1.105, 95% CI =1.021-1.197,\u0026nbsp;P=0.013) as an independent predictors of AGI (Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnivariable and multivariable logistic regression on predictors associated with AGI\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"686\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eUnivariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eMultivariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eOR 95%CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eOR 95%CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eAge, month\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.991\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.981-1.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.095\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eWeight, kg\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.896-0.993\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0.927\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e0.867-0.991\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eSex (male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.061-4.194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e2.520\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e1.093-5.810\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eCyanotic disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.671\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.294-5.515\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0.691\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e0.262-1.822\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.455\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eCross clamp duration, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.003-1.019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0.996\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e0.892-1.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.576\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eRACHS-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3.433\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.608-7.327\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.860\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e0.667-5.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.235\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003ePreoperative IAH, mmHg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.007-1.761\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e0.922-1.792\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eCPB time, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.007-1.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e1.003-1.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eIntraoperative lactic acid, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.070-1.620\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0.881\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e0.707-1.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.255\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eVIS24hmax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.071-1.224\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e1.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e1.021-1.197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eRACHS-1, The risk adjustment in congenital heart surgery-1; VIS, Vasoactive-Inotropic Score; CPB, cardiopulmonary bypass; IAH, intra-abdominal pressure.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.4. \u0026nbsp;Pre- and Post-operative anthropometric measurements of abdominal morphology\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 6, the anthropometric measurements of abdominal morphology including Sagittal abdominal diameter/Transverse abdominal diameter, AVI, and AP significantly increased immediately after surgery. Of those changes, Sagittal abdominal diameter /Transverse abdominal diameter at ICU admission vs. baseline as [0.641(0.590,0.682) vs. 0.615(0.561,0.670), p＜0.001], AVI at ICU admission vs. baseline as [3.213(2.469,3.873) vs. 2.976(2.350,3.748), p＜0.001], AP at ICU admission vs. baseline as [40.7(37.0,44.8) vs. 40.5(36.0,44.0), p＜0.001]. Also, the changes of anthropometric measurements of abdominal morphology were more obvious in the AGI group within 24 hours after surgery (Table 7).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePerioperative anthropometric measurements of abdominal morphology\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"775\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eICU admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eICU 12hr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eICU 24hrs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAP, mm\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e40.5\u003c/p\u003e\n \u003cp\u003e(36.0,44.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e40.7\u003c/p\u003e\n \u003cp\u003e(37.0,44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e40.8\u003c/p\u003e\n \u003cp\u003e(36.7,45.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003cp\u003e(37.1,44.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSagittal abdominal diameter/Transverse abdominal diameter\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0.615\u003c/p\u003e\n \u003cp\u003e(0.56,0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.641\u003c/p\u003e\n \u003cp\u003e(0.59,0.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e0.651\u003c/p\u003e\n \u003cp\u003e(0.60,0.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.654\u003c/p\u003e\n \u003cp\u003e(0.60,0.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAVI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2.976\u003c/p\u003e\n \u003cp\u003e(2.35,3.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.213\u003c/p\u003e\n \u003cp\u003e(2.47,3.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e3.115\u003c/p\u003e\n \u003cp\u003e(2.49,3.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2.873\u003c/p\u003e\n \u003cp\u003e(2.49,3.689)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eIAP, mmHg\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e(2,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e(5,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e(5,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e(5,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSmall bowel lumen size, cm\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.68\u003c/p\u003e\n \u003cp\u003e(1.22,2.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.32\u003c/p\u003e\n \u003cp\u003e(1.64,2.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e2.15\u003c/p\u003e\n \u003cp\u003e(1.65,2.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1.91\u003c/p\u003e\n \u003cp\u003e(1.48,2.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eLarge bowel lumen size, cm\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003cp\u003e(1.50,2.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.86\u003c/p\u003e\n \u003cp\u003e(2.06,3.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e2.62\u003c/p\u003e\n \u003cp\u003e(1.98,3.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2.35\u003c/p\u003e\n \u003cp\u003e(1.73,3.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAscites\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as median (IQR) for continuous variables, and n (%) for categorical variables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAP, abdominal perimeter; AVI, abdominal volume index; IAP, intra-abdominal pressure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbdominal Parameters and Pressure between Patients with or without AGI at ICU admission,12hrs,24hrs.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003ePatients with AGI\u003c/p\u003e\n \u003cp\u003e(n=60)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePatients without AGI\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eThe rate of AP change\u003c/p\u003e\n \u003cp\u003eICU admission/Baseline\u003c/p\u003e\n \u003cp\u003eICU 12hrs/Baseline\u003c/p\u003e\n \u003cp\u003eICU 24hrs/Baseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.032 (1.001,1.064)\u003c/p\u003e\n \u003cp\u003e1.036 (1.006,1.083)\u003c/p\u003e\n \u003cp\u003e1.055 (1.013,1.082)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.006 (0.997,1.029)\u003c/p\u003e\n \u003cp\u003e1.004 (0.988,1.054)\u003c/p\u003e\n \u003cp\u003e1.016 (0.988,1.054)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eSagittal abdominal diameter/Transverse abdominal diameter\u003c/p\u003e\n \u003cp\u003eICU admission/Baseline\u003c/p\u003e\n \u003cp\u003eICU 12hrs/Baseline\u003c/p\u003e\n \u003cp\u003eICU 24hrs/Baseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.672 (0.627,0.714)\u003c/p\u003e\n \u003cp\u003e0.669 (0.631,0.723)\u003c/p\u003e\n \u003cp\u003e0.669 (0.613,0.712)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.629 (0.588,0.672)\u003c/p\u003e\n \u003cp\u003e0.624 (0.588,0.672)\u003c/p\u003e\n \u003cp\u003e0.628 (0.687,0.669)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eThe rate of AVI change\u003c/p\u003e\n \u003cp\u003eICU admission/Baseline\u003c/p\u003e\n \u003cp\u003eICU 12hrs/Baseline\u003c/p\u003e\n \u003cp\u003eICU 24hrs/Baseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.047 (1.010,1.135)\u003c/p\u003e\n \u003cp\u003e1.098 (1.008,1.175)\u003c/p\u003e\n \u003cp\u003e1.086 (1.015,1.177)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.033 (0.996,1.060)\u003c/p\u003e\n \u003cp\u003e1.038 (1.001,1.098)\u003c/p\u003e\n \u003cp\u003e1.066 (1.004,1.107)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003cp\u003e0.157\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eThe rate of small bowel lumen size change\u003c/p\u003e\n \u003cp\u003eICU admission/Baseline\u003c/p\u003e\n \u003cp\u003eICU 12hrs/Baseline\u003c/p\u003e\n \u003cp\u003eICU 24hrs/Baseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.321 (1.252,1.514)\u003c/p\u003e\n \u003cp\u003e1.336 (1.235,1.604)\u003c/p\u003e\n \u003cp\u003e1.287 (1.204,1.517)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.308 (1.194,1.503)\u003c/p\u003e\n \u003cp\u003e1.274 (1.148,1.533)\u003c/p\u003e\n \u003cp\u003e1.211 (1.092,1.374)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.283\u003c/p\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eThe rate of large bowel lumen size change\u003c/p\u003e\n \u003cp\u003eICU admission/Baseline\u003c/p\u003e\n \u003cp\u003eICU 12hrs/Baseline\u003c/p\u003e\n \u003cp\u003eICU 24hrs/Baseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.249 (1.171,1.456)\u003c/p\u003e\n \u003cp\u003e1.186 (1.104,1.387)\u003c/p\u003e\n \u003cp\u003e1.183 (1.076,1.355)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.301 (1.207,1.371)\u003c/p\u003e\n \u003cp\u003e1.244 (1.123,1.382)\u003c/p\u003e\n \u003cp\u003e1.181 (1.049,1.336)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.404\u003c/p\u003e\n \u003cp\u003e0.740\u003c/p\u003e\n \u003cp\u003e0.779\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eAscites\u003c/p\u003e\n \u003cp\u003eICU admission/Baseline\u003c/p\u003e\n \u003cp\u003eICU 12hrs/Baseline\u003c/p\u003e\n \u003cp\u003eICU 24hrs/Baseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (13/16)\u003c/p\u003e\n \u003cp\u003e18 (18/27)\u003c/p\u003e\n \u003cp\u003e21 (21/30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (3/16)\u003c/p\u003e\n \u003cp\u003e9 (9/27)\u003c/p\u003e\n \u003cp\u003e9 (9/30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAP, abdominal perimeter; AVI, abdominal volume index; IAP, intra-abdominal pressure; ICU, intensive care unit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.5. \u0026nbsp;Pre- and Post-operative abdominal contents\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSmall and large bowel lumen size measured by abdominal ultrasound significantly increased immediately after surgery [Small bowel lumen size ICU admission vs. baseline as [2.32 (1.64,2.80) vs. 1.68 (1.22,2.05), p＜0.001]; Large bowel lumen size ICU admission vs. baseline as [2.86 (2.06,3.31) vs. 2.12 (1.50,2.62), p＜0.001] almostly remained dilatable within the first 24 hours in ICU. But in addition to the ratio of small bowel diameter at ICU 12 hrs, we observed no significant difference between AGI and non-AGI groups in the ratio of small and large bowel diameter (Table 7). However, 30 patients (21.89%) had ascites within 24 hours after surgery revealed by abdominal ultrasound (Table 6). The incidence of ascites in AGI patients (35%) was 3 times more than that in non-AGI patients (11.68%) (Table 7).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe study presents the first preliminary clinical investigation of AGI following pediatric cardiac surgery. Our findings highlight three key observations: (1) AGI is a relatively common complication in pediatric cardiac surgery with CPB and contributed to adverse clinical outcomes; (2) The occurrence of AGI is potentially driven by several modifiable factors during cardiac surgery; and (3) early anthropometric measurements of abdominal morphology may serve as a predictive indicator for severe AGI.\u003c/p\u003e \u003cp\u003eThis study found that the incidence of AGI was 43.79%, significantly lower than the 67.3% incidence reported in adult cardiac surgery patients \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e but within the range reported in other critically ill children (14.1%-58.5%) \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. We found that AGI was significantly associated with adverse outcomes in pediatric cardiac surgery patients, aligning with prior evidence linking AGI to poor prognosis in both adult cardiac surgery \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e and critically ill pediatric populations \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Importantly, our study also revealed AGI as an independent risk factor for composite outcome.Clinicians should attach great importance to the occurrence of AGI after cardiac surgery.\u003c/p\u003e \u003cp\u003eOur study identified the longer CPB time as independent perioperative risk factor for the development of AGI. Yang and colleagues \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e reported that CPB duration\u0026thinsp;\u0026ge;\u0026thinsp;132 min as independent risk factor for AGI in patients undergoing heart valve replacement. The mechanisms underlying CPB-induced AGI encompass a multifaceted pathway.During CPB, the gastrointestinal tract underwent hypoxia, hypoperfusion, and stress. Combined with ischemia-reperfusion injury, systemic inflammation, and perioperative vasoactive drug use, these factors collectively leaded to intestinal epithelial damage, barrier dysfunction, and increased permeability, culminating in gastrointestinal injury \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Our study also demonstrated that high-dose vasoactive drugs contributed to the occurrence of AGI following cardiac surgery.We hypothesize that excessive vasoactive drugs may cause significant vasoconstriction in the gastrointestinal tract, leading to reduced perfusion and thereby increasing the risk of AGI. This speculation was supported by evidence demonstrating that abdominal visceral organ function and blood perfusion were served as reliable indicators for evaluating gastrointestinal function \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIAH serves as a diagnostic criterion for AGI.The previous study suggested that peritoneal-to-abdominal height ratio (PAR)\u0026thinsp;\u0026ge;\u0026thinsp;0.52 and the ratio of maximal anteroposterior to transverse abdominal diameter\u0026thinsp;\u0026gt;\u0026thinsp;0.8 could help clinicians to identify IAH on abdominal computed tomography (CT) scan \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. The underlying mechanism might involved increased intra-abdominal content elevating IAP and altering abdominal compliance, triggering sequential abdominal remodeling, stretching, and compression.This resulted in distinct morphological changes (elliptical\u0026rarr;ellipsoidal\u0026rarr;spherical) \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Although the pediatric abdominal wall possesses distinct characteristic,such as reduced thickness, greater pliability, underdeveloped musculature and connective tissue, which can confer greater compliance and an enhanced capacity to accommodate elevations in IAP. Notably, our study found that all pediatric patients undergoing cardiac surgery exhibited immediate postoperative increases in intra-abdominal content(including bowel content and ascites detected by ultrasound), leading to elevated IAP and subsequent abdominal morphological changes (increased sagittal abdominal diameter/transverse abdominal diameter, AVI, and AP). These alterations were significantly more obvious in patients who developed AGI. Morever, Gao et al. developed an AGI ultrasound (AGIUS) score incorporating bowel diameter, wall thickness, and peristalsis, demonstrating a positive correlation with gastrointestinal injury in critically ill patients \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. Gastrointestinal ultrasound represents a non-invasive monitoring tool. Our study observed that pediatric patients undergoing cardiac surgery exhibited varying degrees of intestinal dilation postoperatively, suggesting that GIUS may have significant promise for assessing AGI in this population. However, its clinical application is currently limited by the lack of age-specific reference ranges for intestinal parameters during developmental stages. Our work addressed a critical gap by establishing a significant link between early alterations in abdominal anthropometry and the development of AGI in pediatric patients after cardiac surgery.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the single-center design with a relatively small sample size (n\u0026thinsp;=\u0026thinsp;137) may restrict the generalizability of the findings. Second, the diagnosis of AGI was subjective, and the majority of patients required postoperative mechanical ventilation, which may have resulted in an underestimation of the true AGI incidence. Third, the ultrasound-based measurement of intestinal diameter was subjective and could be affected by abdominal distension. Finally, dynamic changes in intra-abdominal organ volumes were not evaluated.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003ePostoperative AGI is a common complication in pediatric cardiac surgery and is associated with adverse outcomes. Prolonged CPB and high-dose vasoactive drugs may predict AGI. Early postoperative changes in abdominal anthropometric measurements could serve as an early warning indicator.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDeclaration of competing interest\u003c/h2\u003e \u003cp\u003eThe authors have no conflicts of interest or disclosures to report.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eThe used data were publicly available and approved by their corresponding institutions. The study protocol was approved by The Biomedical Research Ethics Committee of West China Hospital of Sichuan University (Approval number 2020(1227)) on February 25, 2021 and was registered (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.chictr.org.cn\u003c/span\u003e\u003cspan address=\"https://www.chictr.org.cn\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, registration number: ChiCTR2100044840) before participants enrollment.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study did not receive any commercial sponsorship.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors have made substantial and intellectual contributions to the work and approved the submitted article. Lijing Deng conceived and designed this study. Data collection, analyses, interpretation and visualisation were performed by Shouping Wang, Wang Niu, and Jiarong Zeng. The manuscript was written by Shouping Wang, Wang Niu, and Lijing Deng revised it critically for important intellectual content. All authors confirm that they had full access to all the data in the study and accept the responsibility to submit for publication. Shouping Wang and Wang Niu contributed equally to this work, and list as co-first author.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData from the present study was available to all researchers upon application. The detailed information and codes required to reanalyze the data in this work are available from the corresponding author (Lijing Deng) upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDolk H, Loane M, Garne E, for the European Surveillance of Congenital Anomalies (EUROCAT) Working Group. Congenital heart defects in Europe: prevalence and perinatal mortality, 2000 to 2005. 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PMID: 21868501.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYue C, Su L, Wang J, Cui N, Zhou Y, Cheng W, Tang B, Rui X, He H, Long Y. Prediction of mechanical ventilation outcome by early abdominal-visceral-blood-flow-and-function score in critically ill patients after cardiopulmonary bypass in the ICU: A prospective observational study. J Intensive Med. 2023;4(1):101\u0026ndash;7. PMID: 38263967; PMCID: PMC10800766.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBouveresse S, Piton G, Badet N, Besch G, Pili-Floury S, Delabrousse E. Abdominal compartment syndrome and intra-abdominal hypertension in critically ill patients: diagnostic value of computed tomography. Eur Radiol. 2019;29(7):3839\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00330-018-5994-x\u003c/span\u003e\u003cspan address=\"10.1007/s00330-018-5994-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2019 Feb 8. PMID: 30737569.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao T, Cheng MH, Xi FC, Chen Y, Cao C, Su T, Li WQ, Yu WK. Predictive value of transabdominal intestinal sonography in critically ill patients: a prospective observational study. Crit Care. 2019;23(1):378. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13054-019-2645-9\u003c/span\u003e\u003cspan address=\"10.1186/s13054-019-2645-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 31775838; PMCID: PMC6880579.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acute gastrointestinal injury, Pediatric patients, Prognosis","lastPublishedDoi":"10.21203/rs.3.rs-8372476/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8372476/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAcute gastrointestinal injury (AGI) encompasses structural or functional gastrointestinal tract dysfunction arising from various stress conditions in critically ill patients. Although it is a well recognized complication in adult cardiovascular surgery patients, its prevalence and risk factors in pediatric population remain unclear. This study sought to: (1) investigate the incidence and prognostic influence of AGI, and (2) identify the risk factors and clinical characteristics associated with AGI in pediatric patients undergoing open-heart surgery with cardiopulmonary bypass(\u0026zwnj;CPB).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a prospective observational study conducted in a single center. The pediatric patients undergoing open-heart surgery with CPB between April 2021 and December 2021 were included. Data collection included demographics, operative details, gastrointestinal symptoms, intra-abdominal pressure(IAP), anthropometric parameters of abdominal morphology, and clinical outcomes. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for AGI. A P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAnalysis of 137 pediatric patients revealed that AGI occurred in 60 patients (43.8%) following open-heart surgery with CPB. Patients with AGI experienced a higher rates of low cardiac output syndrome(LCOS), postoperative infections, and composite outcome (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Furthermore, these patients required greater vasopressor support and experienced longer durations of mechanical ventilation and ICU/hospital stays. Multivariable logistic regression identified AGI as an independent risk factor for the composite outcome (odds ratio [OR] 3.44, 95% confidence interval [CI] 1.28\u0026thinsp;~\u0026thinsp;9.27; P\u0026thinsp;=\u0026thinsp;0.015). Multivariate analysis also identified a longer \u0026zwnj;CPB time (OR 1.01, 95% CI: 1.00\u0026thinsp;~\u0026thinsp;1.02; P\u0026thinsp;=\u0026thinsp;0.007) and a higher intraoperative Vasoactive-Inotropic Score (VIS) (OR 1.11, 95% CI: 1.02\u0026thinsp;~\u0026thinsp;1.20; P\u0026thinsp;=\u0026thinsp;0.013) as independent perioperative risk factors for AGI. Postoperative abdominal morphology demonstrated significant alterations, which were more pronounced in the AGI group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAGI represents a significant clinical concern in pediatric cardiac surgery, where its presence is consistently linked to an adverse postoperative outcome. Prolonged CPB duration and high-dose intraoperative vasoactive drug administration are potential predictive factors for AGI development. Notably, early postoperative alterations in abdominal anthropometric measurements may provide an early non-invasive warning indicator for AGI identification, enabling timely intervention and potentially improving clinical outcomes.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eClinicalTrials.gov Identifier ChiCTR2100044840 on March 30, 2021\u003c/p\u003e","manuscriptTitle":"Acute gastrointestinal injury after pediatric cardiac surgery: A single-center prospective observational study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 08:17:02","doi":"10.21203/rs.3.rs-8372476/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-04T09:24:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-02T18:35:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-01T14:47:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58416937024090217107553589223075965110","date":"2026-01-26T16:56:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274717750008696700590289073094179077159","date":"2026-01-23T10:55:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158556842208395145214361841026041370222","date":"2026-01-21T19:06:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60382245355559001610804931539179185707","date":"2026-01-21T08:54:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-14T06:45:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-17T06:02:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-17T05:41:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-17T05:41:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-12-16T06:10:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cff55470-db02-4033-863d-24c7914b6175","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-20T08:17:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-20 08:17:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8372476","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8372476","identity":"rs-8372476","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}