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Landry LM, Gajula V, Knudson JD, Jenks CL. Haemodynamic effects of prophylactic post-operative hydrocortisone following cardiopulmonary bypass in neonates undergoing cardiac surgery. Cardiol Young 2023; 33:2504-2510. [PMID: 36950894 DOI: 10.1017/s1047951123000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Multiple studies have endeavoured to define the role of steroids in paediatric congenital heart surgery; however, steroid utilisation remains haphazard. In September, 2017, our institution implemented a protocol requiring that all neonates undergoing cardiac surgery with the use of cardiopulmonary bypass receive a five-day post-operative hydrocortisone taper. This single-centre retrospective study was designed to test the hypothesis that routine post-operative hydrocortisone administration reduces the incidence of capillary leak syndrome, leads to favourable postoperative fluid balance, and less inotropic support in the early post-operative period. Data were gathered on all term neonates who underwent cardiac surgery with the use of bypass between September, 2015 and 2019. Subjects who were unable to separate from bypass, required long-term dialysis, or long-term mechanical ventilation were excluded. Seventy-five patients met eligibility criteria (non-hydrocortisone group = 52; hydrocortisone group = 23). For post-operative days 0-4, we did not observe a significant difference in net fluid balance or vasoactive inotropic score between study groups. Similarly, we saw no major difference in secondary clinical outcomes (post-operative duration of mechanical ventilation, ICU/hospital length of stay, and time from surgery to initiation of enteral feeds). In contrast to prior analyses, our study was unable to demonstrate a significant difference in net fluid balance or vasoactive inotropic score with the administration of a tapered post-operative hydrocortisone regimen. Similarly, we saw no effect on secondary clinical outcomes. Further long-term randomised control studies are necessary to validate the potential clinical benefit of utilising steroids in paediatric cardiac surgery, especially in the more fragile neonatal population.
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Affiliation(s)
- Lily M Landry
- Department of Pediatrics, Division of Pediatric Cardiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Viswanath Gajula
- Department of Pediatrics, Division of Pediatric Critical Care, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jarrod D Knudson
- Department of Pediatrics, Division of Pediatric Critical Care, University of Mississippi Medical Center, Jackson, MS, USA
| | - Christopher L Jenks
- Department of Pediatrics, Division of Pediatric Critical Care, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Bronicki RA, Flores S, Loomba RS, Checchia PA, Pollak U, Villarreal EG, Nickerson P, Graham EM. Impact of Corticosteroids on Cardiopulmonary Bypass Induced Inflammation in Children: A Meta-Analysis. Ann Thorac Surg 2020; 112:1363-1370. [PMID: 33309732 DOI: 10.1016/j.athoracsur.2020.09.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 09/01/2020] [Accepted: 09/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Corticosteroids suppress the inflammatory response to cardiopulmonary bypass in children undergoing cardiac surgery. What is less clear is the impact of corticosteroids on the postoperative course. METHODS A systematic review and meta-analysis was made of prospective randomized blinded placebo-controlled trials of pediatric patients who received corticosteroids or saline placebo before surgery was performed. Ten studies met inclusion criteria for a total of 768 patients. In a prespecified subgroup analysis, studies that either were limited to The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery congenital heart surgery mortality categories 1 and 2 or excluded neonates were eliminated and a secondary analysis was conducted, which consisted of seven studies and 555 patients. RESULTS Corticosteroids were associated with a significant improvement in fluid balance at 24 and 36 hours after surgery, with a mean difference of -15.2 mL/kg (95% confidence interval, 25.3 to -5.1 mL/kg; P < .01) and -5.7 mL/kg (95% confidence interval, -9.8 to -1.6 mL/kg; P < .01), respectively. Corticosteroids had no impact on the incidence of infection or mortality. With the secondary analysis, corticosteroids were associated with a trend toward significance in shortening the duration of mechanical ventilation (mean difference -0.7 days; 95% confidence interval, -1.7 to 0.1; P = .08). CONCLUSIONS Corticosteroids were found to have a favorable impact on postoperative fluid balance and may be associated with shortening the duration of mechanical ventilation. Although corticosteroids had no impact on mortality, they may be beneficial particularly for neonates and patients undergoing highly complex surgery.
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Affiliation(s)
- Ronald A Bronicki
- Department of Pediatrics, Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - Saul Flores
- Department of Pediatrics, Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas.
| | - Rohit S Loomba
- Department of Pediatrics, Chicago Medical School, Section of Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Paul A Checchia
- Department of Pediatrics, Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - Uri Pollak
- Department of Pediatrics, Hebrew University-Hadassah Medical School, Hebrew University of Jerusalem, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Enrique G Villarreal
- Department of Pediatrics, Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas; Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo León, México
| | - Parker Nickerson
- Department of Pediatrics, Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - Eric M Graham
- Department of Pediatrics, Medical University of South Carolina, Section of Cardiology, Medical University of South Carolina, Charleston, South Carolina
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Gibbison B, Villalobos Lizardi JC, Avilés Martínez KI, Fudulu DP, Medina Andrade MA, Pérez-Gaxiola G, Schadenberg AW, Stoica SC, Lightman SL, Angelini GD, Reeves BC. Prophylactic corticosteroids for paediatric heart surgery with cardiopulmonary bypass. Cochrane Database Syst Rev 2020; 10:CD013101. [PMID: 33045104 PMCID: PMC8095004 DOI: 10.1002/14651858.cd013101.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Corticosteroids are routinely given to children undergoing cardiac surgery with cardiopulmonary bypass (CPB) in an attempt to ameliorate the inflammatory response. Their use is still controversial and the decision to administer the intervention can vary by centre and/or by individual doctors within that centre. OBJECTIVES This review is designed to assess the benefits and harms of prophylactic corticosteroids in children between birth and 18 years of age undergoing cardiac surgery with CPB. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and Conference Proceedings Citation Index-Science in June 2020. We also searched four clinical trials registers and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA We included studies of prophylactic administration of corticosteroids, including single and multiple doses, and all types of corticosteroids administered via any route and at any time-point in the perioperative period. We excluded studies if steroids were administered therapeutically. We included individually randomised controlled trials (RCTs), with two or more groups (e.g. multi-drug or dose comparisons with a control group) but not 'head-to-head' trials without a placebo or a group that did not receive corticosteroids. We included studies in children, from birth up to 18 years of age, including preterm infants, undergoing cardiac surgery with the use of CPB. We also excluded studies in patients undergoing heart or lung transplantation, or both; studies in patients already receiving corticosteroids; in patients with abnormalities of the hypothalamic-pituitary-adrenal axis; and in patients given steroids at the time of cardiac surgery for indications other than cardiac surgery. DATA COLLECTION AND ANALYSIS We used the Covidence systematic review manager to extract and manage data for the review. Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We resolved disagreements by consensus or by consultation with a third review author. We assessed the certainty of evidence with GRADE. MAIN RESULTS We found 3748 studies, of which 888 were duplicate records. Two studies had the same clinical trial registration number, but reported different populations and interventions. We therefore included them as separate studies. We screened titles and abstracts of 2868 records and reviewed full text reports for 84 studies to determine eligibility. We extracted data for 13 studies. Pooled analyses are based on eight studies. We reported the remaining five studies narratively due to zero events for both intervention and placebo in the outcomes of interest. Therefore, the final meta-analysis included eight studies with a combined population of 478 participants. There was a low or unclear risk of bias across the domains. There was moderate certainty of evidence that corticosteroids do not change the risk of in-hospital mortality (five RCTs; 313 participants; risk ratio (RR) 0.83, 95% confidence interval (CI) 0.33 to 2.07) for children undergoing cardiac surgery with CPB. There was high certainty of evidence that corticosteroids reduce the duration of mechanical ventilation (six RCTs; 421 participants; mean difference (MD) 11.37 hours lower, 95% CI -20.29 to -2.45) after the surgery. There was high-certainty evidence that the intervention probably made little to no difference to the length of postoperative intensive care unit (ICU) stay (six RCTs; 421 participants; MD 0.28 days lower, 95% CI -0.79 to 0.24) and moderate-certainty evidence that the intervention probably made little to no difference to the length of the postoperative hospital stay (one RCT; 176 participants; mean length of stay 22 days; MD -0.70 days, 95% CI -2.62 to 1.22). There was moderate certainty of evidence for no effect of the intervention on all-cause mortality at the longest follow-up (five RCTs; 313 participants; RR 0.83, 95% CI 0.33 to 2.07) or cardiovascular mortality at the longest follow-up (three RCTs; 109 participants; RR 0.40, 95% CI 0.07 to 2.46). There was low certainty of evidence that corticosteroids probably make little to no difference to children separating from CPB (one RCT; 40 participants; RR 0.20, 95% CI 0.01 to 3.92). We were unable to report information regarding adverse events of the intervention due to the heterogeneity of reporting of outcomes. We downgraded the certainty of evidence for several reasons, including imprecision due to small sample sizes, a single study providing data for an individual outcome, the inclusion of both appreciable benefit and harm in the confidence interval, and publication bias. AUTHORS' CONCLUSIONS Corticosteroids probably do not change the risk of mortality for children having heart surgery using CPB at any time point. They probably reduce the duration of postoperative ventilation in this context, but have little or no effect on the total length of postoperative ICU stay or total postoperative hospital stay. There was inconsistency in the adverse event outcomes reported which, consequently, could not be pooled. It is therefore impossible to provide any implications and policy-makers will be unable to make any recommendations for practice without evidence about adverse effects. The review highlighted the need for well-conducted RCTs powered for clinical outcomes to confirm or refute the effect of corticosteroids versus placebo in children having cardiac surgery with CPB. A core outcome set for adverse event reporting in the paediatric major surgery and intensive care setting is required.
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Affiliation(s)
- Ben Gibbison
- Department of Cardiac Anaesthesia and Intensive Care, Bristol Heart Institute/University Hospitals Bristol NHS FT, Bristol, UK
| | | | - Karla Isis Avilés Martínez
- Emergency Pediatric Department, Hospital Civil de Guadalajara "Fray Antonio Alcalde", Guadalajara, Mexico
| | - Daniel P Fudulu
- Department of Cardiac Surgery, University Hospital Bristol NHS Trust, Bristol, UK
| | - Miguel Angel Medina Andrade
- Thoracic and Cardiovascular Department, Hospital Civil Fray Antonio Alcalde de Guadalajara, Guadalajara, Mexico
| | | | - Alvin Wl Schadenberg
- Department of Paediatric Intensive Care, University Hospital Bristol NHS Trust, Bristol, UK
| | - Serban C Stoica
- Department of Paediatric Cardiac Surgery, University Hospital Bristol NHS Trust, Bristol, UK
| | - Stafford L Lightman
- Henry Wellcome Laboratories for Integrative Metabolism and Neuroscience, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Department of Cardiac Surgery, University Hospital Bristol NHS Trust, Bristol, UK
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Keski-Nisula J, Arvola O, Jahnukainen T, Andersson S, Pesonen E. Reduction of Inflammation by High-Dose Methylprednisolone Does not Attenuate Oxidative Stress in Children Undergoing Bidirectional Glenn Procedure With or Without Aortic Arch or Pulmonary Arterial Repair. J Cardiothorac Vasc Anesth 2020; 34:1542-1547. [PMID: 32037273 DOI: 10.1053/j.jvca.2019.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/30/2019] [Accepted: 10/06/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Corticosteroids attenuate an inflammatory reaction in pediatric heart surgery. Inflammation is a source of free oxygen radicals. Children with a cyanotic heart defect are prone to increased radical stress during heart surgery. The authors hypothesized that high-dose methylprednisolone reduces inflammatory reaction and thereby also oxidative stress in infants with a univentricular heart defect undergoing the bidirectional Glenn procedure. DESIGN A double-blind, placebo-controlled, randomized clinical trial. SETTING Operating room and pediatric intensive care unit of a university hospital. PARTICIPANTS The study comprised 29 infants undergoing the bidirectional Glenn procedure with or without aortic arch or pulmonary arterial repair. INTERVENTIONS After anesthesia induction, the patients received intravenously either 30 mg/kg of methylprednisolone (n = 15) or the same volume of saline as placebo (n = 14). MEASUREMENTS AND MAIN RESULTS Plasma interleukin-6, interleukin-8, interleukin-10 (biomarkers of inflammation), and 8-hydroxydeoxyguanosine concentrations (a biomarker of oxidative stress) were measured at the following 4 time points: preoperatively, during cardiopulmonary bypass, after protamine administration, and 6 hours postoperatively. The study parameters did not differ between the study groups preoperatively. Methylprednisolone reduced the proinflammatory cytokines interleukin-6 and interleukin-8 and increased the anti-inflammatory cytokine interleukin-10 postoperatively. Despite reduced inflammation, there were no differences in 8-hydroxydeoxyguanosine between the methylprednisolone and placebo groups. CONCLUSIONS The proinflammatory reaction and increase in free radical stress were not interrelated during congenital heart surgery in cyanotic infants with a univentricular heart defect undergoing the bidirectional Glenn procedure. High-dose methylprednisolone was ineffective in attenuating free radical stress.
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Affiliation(s)
- Juho Keski-Nisula
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Oiva Arvola
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sture Andersson
- Department of Neonatology, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eero Pesonen
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, Kirurginen sairaala, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Fudulu DP, Gibbison B, Upton T, Stoica SC, Caputo M, Lightman S, Angelini GD. Corticosteroids in Pediatric Heart Surgery: Myth or Reality. Front Pediatr 2018; 6:112. [PMID: 29732365 PMCID: PMC5920028 DOI: 10.3389/fped.2018.00112] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/04/2018] [Indexed: 11/17/2022] Open
Abstract
Background: Corticosteroids have been administered prophylactically for more than 60 years in pediatric heart surgery, however, their use remains a matter of debate. There are three main indications for corticosteroid use in pediatric heart surgery with the use of cardiopulmonary bypass (CPB): (1) to blunt the systemic inflammatory response (SIRS) induced by the extracorporeal circuit; (2) to provide perioperative supplementation for presumed relative adrenal insufficiency; (3) for the presumed neuroprotective effect during deep hypothermic circulatory arrest operations. This review discusses the current evidence behind the use of corticosteroids in these three overlapping areas. Materials and Methods: We conducted a structured research of the literature using PubMed and MEDLINE databases to November 2017 and additional articles were identified by cross-referencing. Results: The evidence suggests that there is no correlation between the effect of corticosteroids on inflammation and their effect on clinical outcome. Due to the limitations of the available evidence, it remains unclear if corticosteroids have an impact on early post-operative outcomes or if there are any long-term effects. There is a limited understanding of the hypothalamic-pituitary-adrenal axis function during cardiac surgery in children. The neuroprotective effect of corticosteroids during deep hypothermic circulatory arrest surgery is controversial. Conclusions: The utility of steroid administration for pediatric heart surgery with the use of CPB remains a matter of debate. The effect on early and late outcomes requires clarification with a large multicenter randomized trial. More research into the understanding of the adrenal response to surgery in children and the effect of corticosteroids on brain injury is warranted.
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Affiliation(s)
- Daniel P. Fudulu
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
- Henry Welcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Ben Gibbison
- Cardiac Anesthesia and Intensive Care, Bristol Heart Institute - University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Thomas Upton
- Henry Welcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Serban C. Stoica
- Department of Congenital Cardiac Surgery, Bristol Royal Hospital for Children - University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Massimo Caputo
- Department of Congenital Cardiac Surgery, Bristol Royal Hospital for Children - University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Stafford Lightman
- Henry Welcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Gianni D. Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
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Pesonen E, Keski-Nisula J, Passov A, Vähätalo R, Puntila J, Andersson S, Suominen PK. Heart-Type Fatty Acid Binding Protein and High-Dose Methylprednisolone in Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1952-1956. [PMID: 29066147 DOI: 10.1053/j.jvca.2017.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Corticosteroids possess cardioprotection in experimental cardiac ischemia/reperfusion. The authors hypothesized that if cardioprotection of corticosteroids occured during pediatric cardiac surgery, then methylprednisolone used in cardiopulmonary bypass prime would reduce postoperative concentrations of heart-type fatty-acid-binding protein, a cardiac biomarker. DESIGN A double-blind, placebo-controlled, randomized clinical trial. SETTING Operating room and pediatric intensive care unit of a university hospital. PARTICIPANTS Forty-five infants and young children undergoing ventricular or atrioventricular septal defect correction. INTERVENTIONS The patients received one of the following: 30 mg/kg of methylprednisolone intravenously after anesthesia induction (n = 15), 30 mg/kg of methylprednisolone in cardiopulmonary bypass prime solution (n = 15), or placebo (n = 15). MEASUREMENTS AND MAIN RESULTS Plasma heart-type fatty-acid-binding protein (hFABP) was measured. Preoperatively, hFABP did not differ among the study groups. Methylprednisolone administered preoperatively and in the cardiopulmonary bypass prime solution reduced hFABP by 44% (p = 0.010) and 38% (p = 0.033) 6 hours postoperatively. hFABP significantly correlated with concomitant troponin T after protamine administration (R = 0.811, p < 0.001) and 6 hours postoperatively (R = 0.806, p < 0.001). CONCLUSIONS Methylprednisolone in cardiopulmonary bypass prime solution administered only a few minutes before cardiac ischemia confered cardioprotection of the same magnitude as preoperative methylprednisolone as indicated by hFABP concentrations. Rapid cardioprotective actions of corticosteroids in pediatric heart surgery observed previously experimentally may have occurred.
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Affiliation(s)
- Eero Pesonen
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Juho Keski-Nisula
- Department of Anaesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital; Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Arie Passov
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Raisa Vähätalo
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Anaesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital
| | - Juha Puntila
- Department of Paediatric Cardiac and Transplantation Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sture Andersson
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pertti K Suominen
- Department of Anaesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital; Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Pesonen E, Keski-Nisula J, Andersson S, Palo R, Salminen J, Suominen PK. High-dose methylprednisolone and endothelial glycocalyx in paediatric heart surgery. Acta Anaesthesiol Scand 2016; 60:1386-1394. [PMID: 27604388 DOI: 10.1111/aas.12785] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Corticosteroids are used in paediatric heart surgery to attenuate systemic inflammatory response. Glycocalyx regulates vascular permeability, shear stress and cell adhesion on the endothelium. Syndecan-1 serves as a biomarker of glycocalyx degradation. Hydrocortisone decreased endothelial glycocalyx degradation in an experimental model. Our hypothesis was that high-dose methylprednisolone decreases glycocalyx degradation as measured by plasma sydecan-1 concentration in children undergoing cardiac surgery. METHODS Two double-blinded, randomized, placebo-controlled trials were conducted. In the first trial ('neonatal trial'), 40 neonates undergoing open heart surgery received either 30 mg/kg intravenous methylprednisolone (n = 20) or placebo (n = 20). In the second trial ('VSD trial'), 45 infants and very young children, undergoing ventricular or atrioventricular septal defect correction received one of the following: 30 mg/kg of methylprednisolone intravenously after anaesthesia induction (n = 15), 30 mg/kg methylprednisolone in the cardiopulmonary bypass prime solution (n = 15) or placebo (n = 15). Plasma syndecan-1 concentrations were measured. Results were expressed both as absolute concentrations and in relative concentrations as multiples of the baseline values of syndecan-1. RESULTS There were no statistically significant differences between the neonate trial groups for absolute syndecan-1 concentrations. However, operative administration of methylprednisolone to neonates significantly reduced the relative increases of syndecan-1 at weaning from cardiopulmonary bypass (P = 0.008) and at 6 h post-operatively (P = 0.018). There were no statistically significant differences in absolute or relative increases of syndecan-1 between the VSD trial study groups. CONCLUSION High-dose methylprednisolone reduces shedding of glycocalyx in neonates after complex cardiac surgery but not in older infants after repair of VSD/AVSD with shorter ischaemia times.
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Affiliation(s)
- E. Pesonen
- Division of Anaesthesiology, Peijas Hospital, Department of Anaesthesiology; Intensive Care and Pain Medicine; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - J. Keski-Nisula
- Division of Anaesthesiology; Children's Hospital; Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - S. Andersson
- Children's Hospital; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - R. Palo
- Division of Anaesthesiology; Children's Hospital; Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - J. Salminen
- Department of Paediatric Surgery; Children's Hospital; Helsinki University Hospital and University of Helsinki; Helsinki Finland
| | - P. K. Suominen
- Division of Anaesthesiology; Children's Hospital; Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital; Helsinki Finland
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8
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Keski-Nisula J, Pesonen E, Olkkola KT, Ahlroth T, Puntila J, Andersson S, Neuvonen PJ, Suominen PK. High-Dose Methylprednisolone Has No Benefit Over Moderate Dose for the Correction of Tetralogy of Fallot. Ann Thorac Surg 2016; 102:870-876. [DOI: 10.1016/j.athoracsur.2016.02.089] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
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Abstract
OBJECTIVES The objectives of this review are to discuss the pathophysiology of the pro-inflammatory response to the cardiopulmonary bypass circuit, the impact of ischemia reperfusion injury on post-operative organ function, the compensatory anti-inflammatory response and the evidence for immune-modulatory strategies and their impact on outcomes. DATA SOURCE MEDLINE, PubMed. CONCLUSION Innovations such as the development of more biocompatible surfaces and miniaturized circuits, as well as the increasing expertise of surgeons, anesthesiologists and perfusionists has transformed cardiac surgery and the use of cardiopulmonary bypass into a relatively routine procedure with favorable outcomes. Despite these refinements, the attendant inflammatory response to bypass, ischemia reperfusion injury and the compensatory anti-inflammatory response contribute to post-operative morbidity and mortality. Additional studies are needed to further delineate the impact of immunomodulatory strategies on outcomes.
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10
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Axelrod DM, Alten JA, Berger JT, Hall MW, Thiagarajan R, Bronicki RA. Immunologic and Infectious Diseases in Pediatric Cardiac Critical Care: Proceedings of the 10th International Pediatric Cardiac Intensive Care Society Conference. World J Pediatr Congenit Heart Surg 2016; 6:575-87. [PMID: 26467872 DOI: 10.1177/2150135115598211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Since the inception of the Pediatric Cardiac Intensive Care Society (PCICS) in 2003, remarkable advances in the care of children with critical cardiac disease have been developed. Specialized surgical approaches, anesthesiology practices, and intensive care management have all contributed to improved outcomes. However, significant morbidity often results from immunologic or infectious disease in the perioperative period or during a medical intensive care unit admission. The immunologic or infectious illness may lead to fever, which requires the attention and resources of the cardiac intensivist. Frequently, cardiopulmonary bypass leads to an inflammatory state that may present hemodynamic challenges or complicate postoperative care. However, inflammation unchecked by a compensatory anti-inflammatory response may also contribute to the development of capillary leak and lead to a complicated intensive care unit course. Any patient admitted to the intensive care unit is at risk for a hospital acquired infection, and no patients are at greater risk than the child treated with mechanical circulatory support. In summary, the prevention, diagnosis, and management of immunologic and infectious diseases in the pediatric cardiac intensive care unit is of paramount importance for the clinician. This review from the tenth PCICS International Conference will summarize the current knowledge in this important aspect of our field.
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Affiliation(s)
- David M Axelrod
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jeffrey A Alten
- Section of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - John T Berger
- Division of Critical Care Medicine, George Washington University School of Medicine, Children's National Health System, Washington, DC, USA Division of Cardiology, George Washington University School of Medicine, Children's National Health System, Washington, DC, USA
| | - Mark W Hall
- The Ohio State University College of Medicine, Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ravi Thiagarajan
- Intensive Care Unit, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Ronald A Bronicki
- Section of Critical Care Medicine and Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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11
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Elbarbary M, Madani WH, Robertson‐Malt S. WITHDRAWN: Prophylactic steroids for pediatric open heart surgery. Cochrane Database Syst Rev 2015; 2015:CD005550. [PMID: 26488559 PMCID: PMC6481695 DOI: 10.1002/14651858.cd005550.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The Cochrane Heart Group withdrew this review as the current author team are unable to progress to the final review stage. This title has been taken over by a new author team who are producing a review, starting with a new protocol (Corticosteroids in paediatric heart surgery). The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
| | - Wedad H Madani
- King Saud bin Abdul Aziz University for Health ScienceNational and Gulf Centre of Evidence Based Health PracticeKhashm Al‐AanRiyadhSaudi Arabia
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Keski-Nisula J, Suominen PK, Olkkola KT, Peltola K, Neuvonen PJ, Tynkkynen P, Salminen JT, Andersson S, Pesonen E. Effect of Timing and Route of Methylprednisolone Administration During Pediatric Cardiac Surgical Procedures. Ann Thorac Surg 2015; 99:180-5. [DOI: 10.1016/j.athoracsur.2014.08.042] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 08/20/2014] [Accepted: 08/29/2014] [Indexed: 01/09/2023]
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Robertson-Malt S, El Barbary M. Prophylactic steroids for paediatric open-heart surgery: a systematic review. INT J EVID-BASED HEA 2013; 6:391-5. [PMID: 21631834 DOI: 10.1111/j.1744-1609.2008.00112.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background The immune response to cardiopulmonary bypass in infants and children can lead to a series of post-operative morbidities and mortality, that is, hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the paediatric patient remain unclear. Objectives To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in paediatric open-heart surgery. Search strategy The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional hand-search of the EMRO database for Arabic literature was performed. Grey literature was searched, and experts in the field were contacted for any unpublished material. No language restrictions were applied. Selection criteria All randomised and quasi-randomised controlled trials of open-heart surgery in the paediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality. Data collection and analysis Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model. Main results All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favour of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation (WMD (95% confidence intervals) -0.50 h (-1.41 to 0.41); -0.20°C (-1.16 to 0.77) and -0.63 h (-4.02 to 2.75) respectively).
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Affiliation(s)
- Suzi Robertson-Malt
- JBI Collaboration, National & Gulf Centre for Evidence Based Medicine and National and Gulf Centre for Evidence Based Medicine, Riyadh, Saudi Arabia
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Heying R, Seghaye MC. Reply: To PMID 22289904. Ann Thorac Surg 2013; 96:375-6. [PMID: 23816100 DOI: 10.1016/j.athoracsur.2013.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 03/07/2013] [Accepted: 04/05/2013] [Indexed: 10/26/2022]
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Vitale V, Ricci Z, Cogo P. Preoperative use of steroids in pediatric cardiac surgery: new directions for future research? Ann Thorac Surg 2013; 96:375. [PMID: 23816099 DOI: 10.1016/j.athoracsur.2013.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 10/31/2012] [Accepted: 01/03/2013] [Indexed: 10/26/2022]
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Bronicki RA, Checchia PA, Stuart-Killion RB, Dixon DJ, Backer CL. The effects of multiple doses of glucocorticoids on the inflammatory response to cardiopulmonary bypass in children. World J Pediatr Congenit Heart Surg 2013; 3:439-45. [PMID: 23804905 DOI: 10.1177/2150135112447544] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We previously demonstrated that a dose of glucocorticoids (GCs) administered prior to cardiopulmonary bypass (CPB) is effective at suppressing the inflammatory response to CPB and leads to an improved postoperative course. We evaluated whether an additional dose of GC administered eight hours prior to CPB would lead to further clinical benefit. METHODS We conducted a prospective study in which patients were randomized to receive placebo or GC eight hours prior to CPB, in addition to a dose of GC administered following induction of anesthesia. We measured serum inflammatory mediator levels and postoperative clinical parameters. RESULTS Thirty-one patients were included in the study. Eighteen patients received two doses of GC and 13 patients received a single does of GC. Complement C3a levels were significantly lower at 24 hours following surgery in those patients who received two doses of GC (3136 ± 1650 vs 1779 ± 1616 ng/mL, P = .04). There was no significant difference in tumor necrosis factor (TNF)-α or interleukin (IL)-6 levels at any time between groups. There was no significant difference in core body temperature or renal function (based on serum creatinine levels) between groups. There was no significant difference between groups in duration of mechanical ventilation (2.4 ± 1.5 vs 3.6 ± 3.7 days, two vs one dose, respectively, P = .33) or length of stay in the intensive care unit ([ICU]; 3.4 ± 1.4 vs 4.9 ± 3.6 days, 2 vs 1 dose, respectively, P = .15). CONCLUSION While those patients who received two doses of GC prior to surgery had significantly less complement activation postoperatively, clinical outcomes did not differ between groups. We conclude that the practice of administering an additional dose of GC prior to CPB is not supported. However, a large randomized study is needed to conclusively discount the potential benefit of this strategy.
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Affiliation(s)
- Ronald A Bronicki
- Department of Pediatric Critical Care Medicine, Children's Hospital of Orange County, Orange, CA, USA
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Keski-Nisula J, Pesonen E, Olkkola KT, Peltola K, Neuvonen PJ, Tuominen N, Sairanen H, Andersson S, Suominen PK. Methylprednisolone in Neonatal Cardiac Surgery: Reduced Inflammation Without Improved Clinical Outcome. Ann Thorac Surg 2013; 95:2126-32. [DOI: 10.1016/j.athoracsur.2013.02.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 01/31/2013] [Accepted: 02/06/2013] [Indexed: 11/30/2022]
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Abstract
Pediatric cardiac critical care has made, and continues to make, significant strides in improving outcomes. It is a measure of these successes that much of the discussion in this article does not focus on the reduction of mortality, but rather on perioperative management strategies intended to improve neurologic outcomes. The care of children with critical cardiac disease will continue to rely on broad and collaborative efforts by specialists and primary care practitioners to build on this foundation of success.
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Affiliation(s)
- Ronald A Bronicki
- Cardiac Intensive Care Unit, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA.
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Heying R, Wehage E, Schumacher K, Tassani P, Haas F, Lange R, Hess J, Seghaye MC. Dexamethasone pretreatment provides antiinflammatory and myocardial protection in neonatal arterial switch operation. Ann Thorac Surg 2012; 93:869-76. [PMID: 22289904 DOI: 10.1016/j.athoracsur.2011.11.059] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 11/21/2011] [Accepted: 11/23/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND This prospective double-blinded randomized study tested the hypothesis that preoperative treatment with dexamethasone would attenuate inflammatory priming of the myocardium, reduce the systemic inflammatory reaction upon cardiac operation, and provide organ protection in neonates. METHODS Twenty neonates (age, 8 to 21 days) with transposition of the great arteries scheduled for arterial switch operation were included. Nine received dexamethasone (1 mg/kg body weight) 4 hours before cardiopulmonary bypass, and 11 received natrium chloride. We studied intramyocardial messenger RNA expression of interleukin (IL)-6, IL-8, IL-1β, and tumor necrosis factor-α (TNF-α), as well as IL-10 and expression of TNF-α on protein level in right atrial tissue taken before institution of CPB. We measured plasma levels of IL-6, IL-10, lipopolysaccharide binding protein, and cardiac troponin T. Cytokine expression was related to postoperative outcome. RESULTS Pretreatment with dexamethasone led to a significant decrease in myocardial expression of IL-6, IL-8, IL-1β, and TNF-α messenger RNA and to a decrease in protein synthesis of TNF-α. Plasma concentrations of IL-6 were significantly lower and those of IL-10 significantly higher in pretreated patients. This was associated with lower cardiac troponin T values and lower dobutamine requirement. Levels of lipopolysaccharide binding protein were significantly higher postoperatively in pretreated neonates. CONCLUSIONS Dexamethasone administration before arterial switch operation leads to a shift in the myocardial and systemic cytokine expression profile in neonates with transposition of the great arteries, with downregulation of proinflammatory and upregulation of antiinflammatory cytokines. Lower myocardial cell damage and lower catecholamine requirement suggest myocardial protection in treated patients.
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Affiliation(s)
- Ruth Heying
- Department of Pediatric Cardiology, University Hospital Aachen, Aachen, Germany.
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Bronicki RA, Chang AC. Management of the postoperative pediatric cardiac surgical patient. Crit Care Med 2011; 39:1974-84. [PMID: 21768801 DOI: 10.1097/ccm.0b013e31821b82a6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review the salient aspects and latest advances in the management of the postoperative pediatric cardiac patient. DATA SOURCE A Medline-based literature source. CONCLUSION The practice of pediatric cardiac intensive care has evolved considerably over the last several years. These efforts are the result of a collaborative effort from all subspecialties involved in the care of pediatric patients with congenital heart disease. Discoveries and innovations that are representative of this effort include the extension of cerebral oximetry from the operating room into the critical care setting; mechanical circulatory devices designed for pediatric patients; and surgery in very low birth weight neonates. Advances such as these impact postoperative management and make the field of pediatric cardiac intensive care an exciting, demanding, and evolving discipline, necessitating the ongoing commitment of various disciplines to pursue a greater understanding of disease processes and how to best go about treating them.
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Biomonitors of cardiac injury and performance: B-type natriuretic peptide and troponin as monitors of hemodynamics and oxygen transport balance. Pediatr Crit Care Med 2011; 12:S33-42. [PMID: 22129548 DOI: 10.1097/pcc.0b013e318221178d] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED Serum biomarkers, such as B-type natriuretic peptide and troponin, are frequently measured in the cardiac intensive care unit. A review of the evidence supporting monitoring of these biomarkers is presented. DESIGN A search of MEDLINE, PubMed, and the Cochrane Database was conducted to find literature regarding the use of B-type natriuretic peptide and troponin in the cardiac intensive care setting. Adult and pediatric data were considered. RESULTS AND CONCLUSION Both B-type natriuretic peptide and troponin have demonstrated utility in the intensive care setting but there is no conclusive evidence at this time that either biomarker can be used to guide inpatient management of children with cardiac disease. Although B-type natriuretic peptide and troponin concentrations can alert clinicians to myocardial stress, injury, or hemodynamic alterations, the levels can also be elevated in a variety of clinical scenarios, including sepsis. Observational studies have demonstrated that perioperative measurement of these biomarkers can predict postoperative mortality and complications. RECOMMENDATION AND LEVEL OF EVIDENCE (class IIb, level of evidence B): The use of B-type natriuretic peptide and/or troponin measurements in the evaluation of hemodynamics and postoperative outcome in pediatric cardiac patients may be beneficial.
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de Jong PR, Schadenberg AWL, Jansen NJG, Prakken BJ. Hsp70 and cardiac surgery: molecular chaperone and inflammatory regulator with compartmentalized effects. Cell Stress Chaperones 2009; 14:117-31. [PMID: 18668350 PMCID: PMC2727984 DOI: 10.1007/s12192-008-0066-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Accepted: 07/04/2008] [Indexed: 12/15/2022] Open
Abstract
Open heart surgery is a unique model to study the interplay between cellular injury, regulation of inflammatory responses and tissue repair. Stress-inducible heat shock protein 70-kDa (Hsp70) provides a molecular link between these events. In addition to molecular chaperoning, Hsp70 exerts modulatory effects on endothelial cells and leukocytes involved in inflammatory networks. Hsp70 residing in the intracellular compartment is part of an inhibitory feedback loop that acts on nuclear factor kappaB (NF-kappaB). In contrast, extracellular Hsp70 is recognized by multiple germline-encoded immune receptors, e.g., Toll-like receptor (TLR) 2, TLR4, LOX-1, CD91, CD94, CCR5 and CD40. Hsp70 is thereby able to enhance chemotaxis, phagocytosis and cytolytic activity of innate immune cells and stimulate antigen-specific responses. These apparent contradictory pro- and anti-inflammatory effects of endogenous Hsp70 in the context of cardiac surgery are still not fully understood. An all-embracing model of the compartmentalized effects of endogenous Hsp70 in the orchestration of inflammatory responses in cardiac surgery is proposed.
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Affiliation(s)
- Petrus R. de Jong
- Department of Pediatric Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Home mailbox KC.03.063.0, PO Box 85090, 3508 AB Utrecht, The Netherlands
| | - Alvin W. L. Schadenberg
- Department of Pediatric Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Home mailbox KC.03.063.0, PO Box 85090, 3508 AB Utrecht, The Netherlands
- Department of Pediatric Intensive Care, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Nicolaas J. G. Jansen
- Department of Pediatric Intensive Care, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Lundlaan 6, 3584 EA Utrecht, The Netherlands
| | - Berent J. Prakken
- Department of Pediatric Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Home mailbox KC.03.063.0, PO Box 85090, 3508 AB Utrecht, The Netherlands
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Robertson-Malt S, El Barbary M. Prophylactic steroids for paediatric open-heart surgery: a systematic review. ACTA ACUST UNITED AC 2008; 6:225-233. [PMID: 27820003 DOI: 10.11124/01938924-200806050-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND The immune response to cardiopulmonary bypass in infants and children can lead to a series of post-operative morbidities and mortality, that is, hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the paediatric patient remain unclear. OBJECTIVES To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in paediatric open-heart surgery. SEARCH STRATEGY The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional hand-search of the EMRO database for Arabic literature was performed. Grey literature was searched, and experts in the field were contacted for any unpublished material. No language restrictions were applied. SELECTION CRITERIA All randomised and quasi-randomised controlled trials of open-heart surgery in the paediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality. DATA COLLECTION AND ANALYSIS Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model. MAIN RESULTS All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favour of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation (WMD (95% confidence intervals) -0.50 h (-1.41 to 0.41); -0.20°C (-1.16 to 0.77) and -0.63 h (-4.02 to 2.75) respectively).
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Affiliation(s)
- Suzi Robertson-Malt
- 1. JBI Collaboration, National & Gulf Centre for Evidence Based Medicine 2. National and Gulf Centre for Evidence Based Medicine, Riyadh, Saudi Arabia
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Abstract
BACKGROUND The immune response to cardiopulmonary bypass in infants and children can lead to a series of postoperative morbidities and mortality i.e. hemodynamic instability, increased infection and tachyarrhythmias. Administration of prophylactic doses of corticosteroids is sometimes used to try and ameliorate this pro-inflammatory response. However, the clinical benefits and harms of this type of intervention in the pediatric patient remains unclear. OBJECTIVES To systematically review the beneficial and harmful effects of the prophylactic administration of corticosteroids, compared with placebo, in pediatric open heart surgery. SEARCH STRATEGY The trials registry of the Cochrane Heart Group, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 4, 2006), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) were searched. An additional handsearch of the EMRO database for Arabic literature was performed. Grey literature was searched and experts in the field were contacted for any unpublished material. No language restrictions were applied. SELECTION CRITERIA All randomized and quasi-randomized controlled trials of open heart surgery in the pediatric population that received corticosteroids pre-, peri- or post-operatively, with reported clinical outcomes in terms of morbidity and mortality. DATA COLLECTION AND ANALYSIS Eligible studies were abstracted and evaluated by two independent reviewers. All meta-analyses were completed using RevMan4.2.8. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random-effects model. MAIN RESULTS All cause mortality could not be assessed as the data reports were incomplete. There was weak evidence in favor of prophylactic corticosteroid administration for reducing intensive care unit stay, peak core temperature and duration of ventilation [WMD (95% CI) -0.50 hours (-1.41 to 0.41); -0.20 degrees C (-1.16 to 0.77) and -0.63 hours (-4.02 to 2.75), respectively]. AUTHORS' CONCLUSIONS The use of prophylactic steroids in pediatric patients to reduce postoperative complications commonly experienced following cardiopulmonary bypass surgery is not supported by the existing evidence. Further well designed and adequately powered randomized controlled trials are needed to more accurately estimate the benefit and harm of this intervention.
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Affiliation(s)
- S Robertson-Malt
- King Faisal Specialist Hospital & Research Centre, MBC 01, PO Box 3354, Riyadh, Saudi Arabia, 11211.
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Grosek S, Ihan A, Wraber B, Gabrijelcic T, Kosin M, Osredkar J, Gmeiner G, Grabnar I, Primozic J. Methylprednisolone, cortisol and the cell-mediated immune response in children after ventricular septal defect repair. ACTA ACUST UNITED AC 2007; 45:1366-72. [DOI: 10.1515/cclm.2007.278] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractClin Chem Lab Med 2007;45:1366–72.
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Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C, Tasker R. Year in review in intensive care medicine, 2005. III. Nutrition, pediatric and neonatal critical care, and experimental. Intensive Care Med 2006; 32:490-500. [PMID: 16489423 DOI: 10.1007/s00134-006-0068-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2006] [Accepted: 01/08/2006] [Indexed: 01/15/2023]
Affiliation(s)
- Peter Andrews
- Intensive Care Unit, Western General Hospital, Edinburgh, UK
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