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Lesouhaitier M, Belicard F, Tadié JM. Cardiopulmonary bypass and VA-ECMO induced immune dysfunction: common features and differences, a narrative review. Crit Care 2024; 28:300. [PMID: 39256830 PMCID: PMC11389086 DOI: 10.1186/s13054-024-05058-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 08/06/2024] [Indexed: 09/12/2024] Open
Abstract
Cardiopulmonary bypass (CPB) and veno-arterial extracorporeal membrane oxygenation are critical tools in contemporary cardiac surgery and intensive care, respectively. While these techniques share similar components, their application contexts differ, leading to distinct immune dysfunctions which could explain the higher incidence of nosocomial infections among ECMO patients compared to those undergoing CPB. This review explores the immune modifications induced by these techniques, comparing their similarities and differences, and discussing potential treatments to restore immune function and prevent infections. The immune response to CPB and ECMO involves both humoral and cellular components. The kinin system, complement system, and coagulation cascade are rapidly activated upon blood contact with the circuit surfaces, leading to the release of pro-inflammatory mediators. Ischemia-reperfusion injury and the release of damage-associated molecular patterns further exacerbate the inflammatory response. Cellular responses involve platelets, neutrophils, monocytes, dendritic cells, B and T lymphocytes, and myeloid-derived suppressor cells, all of which undergo phenotypic and functional alterations, contributing to immunoparesis. Strategies to mitigate immune dysfunctions include reducing the inflammatory response during CPB/ECMO and enhancing immune functions. Approaches such as off-pump surgery, corticosteroids, complement inhibitors, leukocyte-depleting filters, and mechanical ventilation during CPB have shown varying degrees of success in clinical trials. Immunonutrition, particularly arginine supplementation, has also been explored with mixed results. These strategies aim to balance the inflammatory response and support immune function, potentially reducing infection rates and improving outcomes. In conclusion, both CPB and ECMO trigger significant immune alterations that increase susceptibility to nosocomial infections. Addressing these immune dysfunctions through targeted interventions is essential to improving patient outcomes in cardiac surgery and critical care settings. Future research should focus on refining these strategies and developing new approaches to better manage the immune response in patients undergoing CPB and ECMO.
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Affiliation(s)
- Mathieu Lesouhaitier
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, 2 rue Henri Le Guilloux, 35033, Rennes, France.
- SITI, Pole de Biologie, Pontchaillou University Hospital, Etablissement Français du Sang Bretagne, 2 rue Henri Le Guilloux, 35033, Rennes, France.
- UMR 1236, Univ Rennes, INSERM, Etablissement Français du Sang Bretagne, Rennes, France.
- CIC-1414, INSERM, Rennes, France.
| | - Félicie Belicard
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, 2 rue Henri Le Guilloux, 35033, Rennes, France
- SITI, Pole de Biologie, Pontchaillou University Hospital, Etablissement Français du Sang Bretagne, 2 rue Henri Le Guilloux, 35033, Rennes, France
- UMR 1236, Univ Rennes, INSERM, Etablissement Français du Sang Bretagne, Rennes, France
| | - Jean-Marc Tadié
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, 2 rue Henri Le Guilloux, 35033, Rennes, France.
- SITI, Pole de Biologie, Pontchaillou University Hospital, Etablissement Français du Sang Bretagne, 2 rue Henri Le Guilloux, 35033, Rennes, France.
- UMR 1236, Univ Rennes, INSERM, Etablissement Français du Sang Bretagne, Rennes, France.
- CIC-1414, INSERM, Rennes, France.
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Nallasamy K, Magee A, Millar KJ, Duke T. Prevalence and outcome of lymphopenia in the Paediatric Intensive Care Unit: A prospective observational study. J Paediatr Child Health 2022; 58:2203-2210. [PMID: 36054491 DOI: 10.1111/jpc.16183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 05/24/2022] [Accepted: 07/21/2022] [Indexed: 11/26/2022]
Abstract
AIM Leukopenia (lymphopenia or neutropenia) may be an important marker of altered immunity and risk in children with critical illness. We aimed to evaluate the prevalence, course, and outcome of leukopenia in children admitted to Paediatric Intensive Care Unit (PICU). METHODS All consecutive children (n = 200) admitted to PICU for any reason except malignancy or pre-existing immune deficiency were enrolled during June-August 2018. RESULTS Median (interquartile range) age was 2.2 (0.6-8.5) years. About 52% (n = 103) had undergone a surgical procedure; 34% (n = 68) being cardiac surgery. Among medical illnesses, respiratory disorders were the most common (n = 39, 20%). Laboratory confirmed infections were present in 63 (31.5%) children. Leukopenia was identified in 135 (67.5%) children in the first week; 117 (58.5%) had only lymphopenia, 16 (8%) had both lymphopenia and neutropenia, and 2 (1%) had only neutropenia. In 69 children who had follow-up blood counts, lymphopenia resolved in 33 (48%) within 48 h and in another 20 (29%) by 4 days, and in a further 10 (14%) by 7 days. Children with lymphopenia had higher frequency of cardiac surgery, longer cardiopulmonary bypass time, greater need for invasive ventilation and vasopressor/inotrope therapy, and a higher probability of organ failure on day 4 and longer hospital stay. CONCLUSION In critically ill children, lymphopenia is very common, often transient, but may be associated with unfavourable outcomes. Further studies with follow-up of blood counts in a larger sample are required to determine the course and outcomes of lymphopenia.
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Affiliation(s)
- Karthi Nallasamy
- Pediatric Intensive Care Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aidan Magee
- Pediatric Intensive Care Unit, The Children's Hospital, Westmead, Sydney, New South Wales, Australia
| | - K Johnny Millar
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Trevor Duke
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Post-operative kinetics of C-reactive protein to distinguish between bacterial infection and systemic inflammation in infants after cardiopulmonary bypass surgery: the early and the late period. Cardiol Young 2022; 32:904-911. [PMID: 34365991 DOI: 10.1017/s1047951121003231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Differentiation between post-operative inflammation and bacterial infection remains an important issue in infants following congenital heart surgery. We primarily assessed kinetics and predictive value of C-reactive protein for bacterial infection in the early (days 0-4) and late (days 5-28) period after cardiopulmonary bypass surgery. Secondary objectives were frequency, type, and timing of post-operative infection related to the risk adjustment for congenital heart surgery score. METHODS This 3-year single-centre retrospective cohort study in a paediatric cardiac ICU analysed 191 infants accounting for 235 episodes of CPBP surgery. Primary outcome was kinetics of CRP in the first 28 days after CPBP surgery in infected and non-infected patients. RESULTS We observed 22 infectious episodes in the early and 34 in the late post-operative period. CRP kinetics in the early post-operative period did not accurately differentiate between infected and non-infected patients. In the late post-operative period, infected infants displayed significantly higher CRP values with a median of 7.91 (1.64-22.02) and 6.92 mg/dl (1.92-19.65) on days 2 and 3 compared to 4.02 (1.99-15.9) and 3.72 mg/dl (1.08-9.72) in the non-infection group. Combining CRP on days 2 and 3 after suspicion of infection revealed a cut-off of 9.47 mg/L with an acceptable predictive accuracy of 76%. CONCLUSIONS In neonates and infants, CRP kinetics is not useful to predict infection in the first 72 hours after CPBP surgery due to the inflammatory response. However, in the late post-operative period, CRP is a valuable adjunctive diagnostic test in conjunction with clinical presentation and microbiological diagnostics.
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Derangement of Arginine and Related Amino Acids in Children Undergoing Surgery for Congenital Heart Disease With Cardiopulmonary Bypass. Crit Care Explor 2020; 2:e0150. [PMID: 32766551 PMCID: PMC7368881 DOI: 10.1097/cce.0000000000000150] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Supplemental Digital Content is available in the text. Arginine is a conditionally essential amino acid, the precursor for nitric oxide and a key factor in cell proliferation, protein synthesis, and energy metabolism. When there is increased demand in the setting of inflammation, ischemia-reperfusion injury, and organ dysfunction, endogenous arginine production falls short, and external supplementation may be necessary. The goal of this study was to assess changes in concentrations of plasma arginine, citrulline, ornithine, glutamine, and plasma arginase in infants and children undergoing surgery for congenital heart disease with cardiopulmonary bypass.
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Jiménez-Aguilar R, Sánchez-Zauco N, Tiburcio-Felix R, López JZ, Solano-Gutiérrez A, Riera C, Reyes-Maldonado E, Maldonado-Bernal C. Effects of cardiopulmonary bypass on the development of lymphopenia and sepsis after cardiac surgery in children with congenital cardiopathy. Exp Ther Med 2019; 19:435-442. [PMID: 31885693 PMCID: PMC6913339 DOI: 10.3892/etm.2019.8241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 05/30/2019] [Indexed: 12/20/2022] Open
Abstract
The objective of the present study was to investigate whether lymphopenia occurring after heart surgery with cardiopulmonary bypass (CPB) is related to apoptosis and or sepsis in children. The design was a prospective cohort study in a third level care hospital in Mexico City. In total, 68 children (31 girls and 37 boys) with congenital cardiopathy who needed corrective cardiac surgery with or without CPB were included. The samples were obtained from central blood before, immediately after and 24 h after surgery. Complete blood counts and lymphocyte apoptosis were analyzed. Systemic inflammatory response syndrome (SIRS), sepsis and the type of microorganism were recorded. A total of 53 patients received CPB and 15 did not. Lymphocyte count decreased after surgery in both groups (P<0.001). However, neutrophil count increased markedly in both groups. Apoptosis of B (CD19+) lymphocytes was higher in the non-CPB group (14, 2 and 21% before, immediately after and 24 h after surgery, respectively) than the CPB group (0, 2 and 3%, respectively), but apoptosis of cytotoxic T lymphocytes (CD8+) was higher in the CPB group (5, 4 and 3% before, immediately after and 24 h after surgery, respectively) than in the non-CPB group (2, 3 and 2%, respectively). However, the extent of apoptosis of T and B lymphocytes after surgery did not differ between groups. The CPB group had more complications than the non-CPB group [38 (71.7%) vs. 9 (60.0%)]. In conclusion, the decrease in lymphocyte count may be related to apoptosis of cytotoxic T lymphocytes in children receiving cardiac surgery with CPB and to apoptosis of B lymphocytes in those not receiving CPB. The decreased lymphocyte counts in both groups suggested that CPB is not the main cause of this decrease. Children who received CPB during surgery had more complications, such as sepsis and cardiogenic shock than did those who did not receive CPB.
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Affiliation(s)
- Rosalinda Jiménez-Aguilar
- Terapia Intensiva, Unidad Médica de Alta Especialidad, Hospital General Gaudencio González de la Garza, Centro Médico Nacional 'La Raza', IMSS, Mexico City C.P. 02990, México.,Departamento de Morfología, Laboratorio de Bacteriología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City C.P. 11350, México
| | - Norma Sánchez-Zauco
- División de Auxiliares de Diagnóstico y Tratamiento UMAE, Hospital de Especialidades, Centro Médico Nacional-Siglo XXI, IMSS, Mexico City C.P. 06725, México
| | - Reynaldo Tiburcio-Felix
- Departamento de Genética y Biología Molecular, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mexico City C.P. 07240, México
| | - Jorge Zavala López
- Departamento de Circulación Extracorporea, Hospital de Pediatría del Centro Médico Nacional SXXI, Mexico City C.P. 06725, México
| | - Alejandro Solano-Gutiérrez
- Servicio de Cirugía Cardiovascular, Hospital de Cardiología del Centro Médico Nacional Siglo XXI, IMSS, Unidad Médica de Alta Especialidad, Mexico City C.P. 06725, México
| | - Carlos Riera
- Departamento de Circulación Extracorporea, Hospital de Pediatría del Centro Médico Nacional SXXI, Mexico City C.P. 06725, México
| | - Elba Reyes-Maldonado
- Departamento de Morfología, Laboratorio de Bacteriología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City C.P. 11350, México
| | - Carmen Maldonado-Bernal
- Laboratorio de Investigación en Inmunología y Proteómica, Hospital Infantil de México Federico Gómez, Mexico City C.P. 06171, México
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Kapitein B, van Saet AW, Golab HD, de Hoog M, de Wildt S, Tibboel D, Bogers AJJC. Does pharmacotherapy influence the inflammatory responses during cardiopulmonary bypass in children? J Cardiovasc Pharmacol 2015; 64:191-7. [PMID: 24949583 DOI: 10.1097/fjc.0000000000000098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Cardiopulmonary bypass (CPB) induces a systemic inflammatory response syndrome (SIRS) by factors such as contact of the blood with the foreign surface of the extracorporeal circuit, hypothermia, reduction of pulmonary blood flow during CPB and endotoxemia. SIRS is maintained in the postoperative phase, co-occurring with a counter anti-inflammatory response syndrome. Research on the effects of drugs administered before the surgery, especially in the induction phase of anesthesia, as well as drugs used during extracorporeal circulation, has revealed that they greatly influence these postoperative inflammatory responses. A better understanding of these processes may not only improve postoperative recovery but also enable tailor-made pharmacotherapy, with both health and economic benefits. In this review, we describe the pathophysiology of SIRS and counter anti-inflammatory response syndrome in the light of CPB in children and the influence of drugs used on these syndromes.
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Affiliation(s)
- Berber Kapitein
- *Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; †Department of Anesthesiology, Intensive Care Unit, Erasmus MC, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; and ‡Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, the Netherlands
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Troubleshooting the rat model of cardiopulmonary bypass: effects of avoiding blood transfusion on long-term survival, inflammation and organ damage. J Pharmacol Toxicol Methods 2013; 67:82-90. [PMID: 23328058 DOI: 10.1016/j.vascn.2013.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 12/09/2012] [Accepted: 01/03/2013] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Rat models of cardiopulmonary bypass (CPB) have been used to examine the mechanisms of associated organ damage and to test intervention strategies. However, these models only partly mimic the clinical situation, because of the use of blood transfusion and arterial inflow via the tail artery. Thus a model using arterial inflow in the aorta and a miniaturized CPB circuit without need of transfusion was validated by examining intra-procedure characteristics, mortality and the effects of CPB on biomarkers of inflammation and cerebral injury during 5days follow-up. METHODS Male Wistar rats (n=95) were anesthetized with isoflurane (2.5%) and fentanyl/midazolam during CPB. Animals were assigned to Control (n=6), Sham (n=40) or normothermic CPB (n=49) groups. Both Sham and CPB were cannulated in the aorta via the left carotid artery and in the right common jugular vein for access into the right heart. Extracorporeal circulation (ECC) was instituted for 60min only in CPB at a flow rate of 120mLkg(-1)min(-1) employing a CPB circuit of 15ml primed with 6% hydroxyethyl starch 60mgml(-1) solution. Rats were sacrificed at either 1h or 1, 2 or 5days after Sham or weaning from CPB. Plasma IL-6 and s100Beta levels were measured and blood cell counts were performed. RESULTS Mortality in CPB animals (3 out of 49) and Sham (4 out of 40) did not differ (chi-square=0.46, dF=1, P>0.5). Compared to baseline (1.87±0.46∗10^9cells/L), Sham procedure (cannulation and anesthesia) significantly increased blood neutrophil count at the end of the period matching ECC (6.34±2.36∗10^9cells/L, P<0.05). CPB induced neutrophilia which persisted during 24h recovery. Also, CPB caused a rapid and prominent increase in plasma IL-6 from the first hour of the postoperative period (~1200pg/ml) with continuation (50-90pg/ml) up to 5th day of recovery. S100Beta levels were above detection level only in 3 out of 42 samples from CPB animals. DISCUSSION Our rat model of CPB without homologous blood transfusion produces a reproducible and reliable systemic inflammatory response, with low mortality rates on long term follow up. The model more closely mimics the human situation in respect to arterial inflow site and avoidance of blood transfusion. Thus, our CPB model is suitable to study its influence on systemic inflammation, ischemia-reperfusion injury, microcirculation and vascular dysfunction in vivo, and to evaluate potential therapeutic interventions.
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Gardner AH, Prodhan P, Stovall SH, Gossett JM, Stern JE, Wilson CD, Fiser RT. Fungal infections and antifungal prophylaxis in pediatric cardiac extracorporeal life support. J Thorac Cardiovasc Surg 2011; 143:689-95. [PMID: 22177096 DOI: 10.1016/j.jtcvs.2011.12.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 09/08/2011] [Accepted: 12/01/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Infections acquired by children during extracorporeal membrane oxygenation (ECMO) increase mortality. Our aim was to evaluate the effectiveness of prophylactic fluconazole on the incidence of fungal infections and to assess whether hospital-acquired fungal infection is associated with increased in-hospital mortality in pediatric cardiac patients requiring ECMO. METHODS We retrospectively reviewed a prospectively maintained database and collected data on all hospital-acquired infections in patients supported for cardiac indications at a tertiary children's hospital from 1989 to 2008. RESULTS ECMO was deployed 801 times in 767 patients. After exclusion criteria were applied, 261 pediatric patients supported for cardiac indications were studied. Fungal infection (blood, urine, or surgical site) occurred in 12% (31/261) of patients, 9 (7%) of 127 patients receiving fluconazole prophylaxis versus 22 (16.4%) of 134 without antifungal prophylaxis (P = .02). Using a multivariable logistic regression model, the absence of fluconazole prophylaxis was associated with an increased risk of fungal infection (odds ratio [OR] = 2.8; 95% confidence intervals [CI], 1.2, 6.7; P = .016). In a multivariable logistic regression model for in-hospital mortality, the presence of fungal infection was associated with increased odds (OR = 3.8; 95% CI, 1.5, 9.6; P = .005) of in-hospital mortality among cardiac patients requiring ECMO, and the absence of antifungal prophylaxis showed a trend toward the same (OR = 1.6; 95% CI, 0.96, 2.8; P = .072). CONCLUSIONS Children with cardiac disease supported with ECMO who acquire fungal infections have increased mortality. Routine fluconazole prophylaxis is associated with lower rates of fungal infections in these patients.
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Affiliation(s)
- Aaron H Gardner
- Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR 72202-3591, USA
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Santillan Salas CF, Joshi AY, Dhiman N, Banerjee R, Huskins WC, Wengenack NL, Henry NK. Fatal post-operative Trichoderma longibrachiatum mediastinitis and peritonitis in a paediatric patient with complex congenital cardiac disease on peritoneal dialysis. J Med Microbiol 2011; 60:1869-1871. [DOI: 10.1099/jmm.0.030718-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Carlos F. Santillan Salas
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, Mayo Clinic College of Medicine and Mayo Eugenio Litta Children’s Hospital, 200 First Street SW, Rochester, MN 55905, USA
| | - Avni Y. Joshi
- Department of Pediatric and Adult Allergy/Immunology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Neelam Dhiman
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Ritu Banerjee
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, Mayo Clinic College of Medicine and Mayo Eugenio Litta Children’s Hospital, 200 First Street SW, Rochester, MN 55905, USA
| | - W. Charles Huskins
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, Mayo Clinic College of Medicine and Mayo Eugenio Litta Children’s Hospital, 200 First Street SW, Rochester, MN 55905, USA
| | - Nancy L. Wengenack
- Department of Laboratory Medicine and Pathology, Division of Clinical Microbiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Nancy K. Henry
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, Mayo Clinic College of Medicine and Mayo Eugenio Litta Children’s Hospital, 200 First Street SW, Rochester, MN 55905, USA
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Abstract
PURPOSE OF REVIEW Adequate nutrition is crucial in children after surgery for congenital heart disease. We address selected nutritional and caloric requirements for children in the perioperative period before and after cardiac surgery and explore nutritional interdependence with other system functions. Recommendations based on our current practice are made at the end of each section. RECENT FINDINGS Early identification of deficient oropharyngeal motor skills and vocal cord dysfunction is crucial to establish enteral nutrition safely and has been demonstrated to improve clinical outcomes. The use of prealbumin as a marker of nutritional state should be accompanied by C-reactive protein given the influence of inflammation on its levels. Insulin infusions may improve outcomes in patients with postoperative hyperglycemia. Trace element abnormalities and early identification of immune-compromised states can aid in reducing morbidity in children after cardiac surgery. Use of feeding protocols and a home surveillance system for hypoplastic left heart syndrome improves outcomes. SUMMARY Adequate nutritional support in children after cardiac surgery is a challenge. Attention to lesion-specific feeding problems, supplementation of trace elements and minerals, and an organized approach to pace, timing, and type of feeding are beneficial.
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