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Park Y, Yu BS, Heo YM, Kyung S, Lee KE, Kim S, Kang S, Han K, Kim DH. Characteristics of Malassezia furfur at various pH and effects of Malassezia lipids on skin cells. Appl Microbiol Biotechnol 2024; 108:455. [PMID: 39231813 PMCID: PMC11374913 DOI: 10.1007/s00253-024-13292-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 08/17/2024] [Accepted: 08/19/2024] [Indexed: 09/06/2024]
Abstract
Malassezia species are commensal and opportunistic fungi found in human skin. All Malassezia species lack fatty acid synthesis genes and survive by utilizing several lipases to degrade and absorb fatty acids from external lipid sources, but little research has been done on their optimal active pH and temperature. Our skin protects itself from external stimuli and maintains homeostasis, involving bacteria and fungi such as Malassezia species that inhabit our skin. Hence, dysbiosis in the skin microbiome can lead to various skin diseases. The skin's pH is slightly acidic compared to neutral, and changes in pH can affect the metabolism of Malassezia species. We used keratinocyte cell lines to determine the effect of lipids bio-converted by Malassezia furfur, Malassezia japonica, and Malassezia yamatoensis under pH conditions similar to those of healthy skin. Lipids bio-converted from Malassezia species were associated with the regulation of transcripts related to inflammation, moisturizing, and promoting elasticity. Therefore, to determine the effect of pH on lipid metabolism in M. furfur, which is associated with seborrheic dermatitis, changes in biomass, lipid content, and fatty acid composition were determined. The results showed that pH 7 resulted in low growth and reduced lipid content, which had a negative impact on skin health. Given that bio-converted Malassezia-derived lipids show positive effects at the slightly acidic pH typical of healthy skin, it is important to study their effects on skin cells under various pH conditions. KEY POINTS: • pH 6, Malassezia spp. bio-converted lipid have a positive effect on skin cells • Malassezia spp. have different lipid, fatty acid, and growth depending on pH • Malassezia spp. can play a beneficial role by secreting lipids to the outside.
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Affiliation(s)
- Yujun Park
- Department of Microbiology, College of Science & Technology, Dankook University, Cheonan, 31116, Republic of Korea
| | - Byung Sun Yu
- Department of Microbiology, College of Science & Technology, Dankook University, Cheonan, 31116, Republic of Korea
- Center for Bio Medical Engineering Core Facility, Dankook University, Cheonan, 31116, Republic of Korea
- Smart Animal Bio Institute, Dankook University, Cheonan, 31116, Republic of Korea
| | - Young Mok Heo
- COSMAX BTI R&I Center, 255, Pangyo-Ro, Bundang-Gu, Seongnam, 13486, Republic of Korea
| | - Seoyeon Kyung
- COSMAX BTI R&I Center, 255, Pangyo-Ro, Bundang-Gu, Seongnam, 13486, Republic of Korea
| | - Kyung-Eun Lee
- COSMAX BTI R&I Center, 255, Pangyo-Ro, Bundang-Gu, Seongnam, 13486, Republic of Korea
| | - Sol Kim
- COSMAX BTI R&I Center, 255, Pangyo-Ro, Bundang-Gu, Seongnam, 13486, Republic of Korea
| | - Seunghyun Kang
- COSMAX BTI R&I Center, 255, Pangyo-Ro, Bundang-Gu, Seongnam, 13486, Republic of Korea
| | - Kyudong Han
- Department of Microbiology, College of Science & Technology, Dankook University, Cheonan, 31116, Republic of Korea.
- Center for Bio Medical Engineering Core Facility, Dankook University, Cheonan, 31116, Republic of Korea.
- Smart Animal Bio Institute, Dankook University, Cheonan, 31116, Republic of Korea.
- Department of Human, Microbiome Research HuNbiome Co. Ltd, R&D Center, Seoul, Republic of Korea.
| | - Dong Hee Kim
- Department of Anesthesiology and Pain Management, Dankook University Hospital, Cheonan, 31116, Korea.
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Losiggio R, Lomivorotov V, D'Andria Ursoleo J, Kotani Y, Monaco F, Milojevic M, Yavorovskiy A, Lee TC, Landoni G. The Effects of Corticosteroids on Survival in Pediatric and Nonelderly Adult Patients Undergoing Cardiac Surgery: A Meta-analysis of Randomized Studies. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00438-5. [PMID: 39147607 DOI: 10.1053/j.jvca.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 07/01/2024] [Indexed: 08/17/2024]
Affiliation(s)
- Rosario Losiggio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Centre, Hershey, PA, USA
| | - Jacopo D'Andria Ursoleo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Centre, Kamogawa, Japan
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands; Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health, Moscow, Russia
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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Takeshita J, Nakajima Y, Tachibana K, Takeuchi M, Shime N. Efficacy of perioperative prophylactic administration of corticosteroids in pediatric cardiac surgeries using cardiopulmonary bypass: a systematic review with meta-analysis. Anaesth Crit Care Pain Med 2023; 42:101281. [PMID: 37499940 DOI: 10.1016/j.accpm.2023.101281] [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: 05/16/2023] [Revised: 07/15/2023] [Accepted: 07/16/2023] [Indexed: 07/29/2023]
Abstract
An updated systematic review with meta-analysis comparing perioperative prophylactic administration of corticosteroids with placebo in pediatric cardiac surgeries using cardiopulmonary bypass was conducted. The Cochrane Central Register of Controlled Trials and MEDLINE (via PubMed) were searched for relevant randomized controlled trials published between January 1, 2000, and February 14, 2023. The primary outcome was postoperative in-hospital mortality. Secondary outcomes were duration of mechanical ventilation, length of intensive care unit and hospital stay, postoperative low cardiac output syndrome, and adverse events. A total of 11 studies were included in the meta-analysis. Corticosteroid administration did not decrease postoperative in-hospital mortality compared with placebo (relative risk, 0.69; 95% confidence interval, 0.40-1.17). Subgroup analyses according to the type of corticosteroids and neonates revealed that corticosteroids did not decrease postoperative in-hospital mortality. In the trial sequential analysis, the last point in the z-curve was within the futility borders. Although the duration of mechanical ventilation (mean difference, -5.54 h; 95% confidence interval (CI), -9.75 - -1.34) and incidence of low cardiac output syndrome (relative risk, 0.75; 95% CI, 0.59 - 0.96) decreased with corticosteroid administration, it did not affect the length of intensive care unit (mean difference, -0.28 days; 95% CI, -0.74 - 0.17) and hospital stay (mean difference, -0.59 days; 95% CI, -1.31 - 0.14). In conclusion, perioperative prophylactic corticosteroid administration in pediatric cardiac surgeries using cardiopulmonary bypass did not decrease postoperative in-hospital mortality compared with placebo. According to the trial sequential analysis results, additional randomized controlled trials assessing mortality are not required. PROSPERO REGISTRY NUMBER: CRD 42023391789.
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Affiliation(s)
- Jun Takeshita
- Department of Anesthesiology, Osaka Prefectural Hospital Organization, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Yasufumi Nakajima
- Department of Anesthesiology and Intensive Care, Kinki University Faculty of Medicine, 377-2 Ohnohigashi, Sayama, Osaka 589-8511, Japan; Outcomes Research Consortium, 9500 Euclid Avenue, P77, Cleveland, OH 44195, USA.
| | - Kazuya Tachibana
- Department of Anesthesiology, Osaka Prefectural Hospital Organization, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Muneyuki Takeuchi
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan.
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, 1-3-2 Kagamiyama, Higashihiroshima, Hiroshima 739-8511, Japan.
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Cheema HA, Khan AA, Ahmad AH, Khan AA, Khalid A, Shahid A, Hermis AH, Syed A, Bansal N, Yuki K, Ghelani SJ, Dani SS. Perioperative prophylactic corticosteroids for cardiac surgery in children: A systematic review and meta-analysis. Am Heart J 2023; 266:159-167. [PMID: 37716449 DOI: 10.1016/j.ahj.2023.09.006] [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] [Received: 06/30/2023] [Revised: 09/12/2023] [Accepted: 09/12/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVE Perioperative corticosteroids have been used for pediatric cardiac surgery for decades, but the underlying evidence is conflicting. We aimed to investigate the efficacy and safety of perioperative prophylactic corticosteroids in pediatric heart surgeries. METHODS We searched electronic databases until March 2023 to retrieve all randomized controlled trials (RCTs) that administered perioperative prophylactic corticosteroids to children undergoing heart surgery. We used RevMan 5.4 to pool risk ratios (RRs) and mean differences (MDs). RESULTS A total of 12 RCTs (2,209 patients) were included in our review. Corticosteroids administration was associated with a nonsignificant reduction in all-cause mortality (RR 0.62; 95% CI: 0.37-1.02, I2 = 0%; moderate certainty); however, it was associated with a lower duration of mechanical ventilation (MV) (MD -0.63 days; 95% CI: -1.16 to -0.09 days, I2 = 41%; high certainty). Corticosteroids did not affect the length of ICU and hospital stay but significantly reduced the incidence of postoperative low cardiac output syndrome (LCOS) (RR 0.76; 95% CI: 0.60-0.96, I2 = 0%; moderate certainty) and reoperation (RR 0.37; 95% CI: 0.19-0.74, I2 = 0%; moderate certainty). There was no increase in adverse events except a higher risk of hyperglycemia and postoperative insulin use. CONCLUSIONS The use of perioperative corticosteroids in pediatric heart surgeries is associated with a trend toward reduced all-cause mortality without attaining statistical significance. Corticosteroids reduced MV duration, and probably decrease the incidence of LCOS, and reoperations. The choice of corticosteroid agent and dose is highly variable and further larger studies may help determine the ideal agent, dose, and patient population for this prophylactic therapy.
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Affiliation(s)
- Huzaifa Ahmad Cheema
- Department of Cardiology, King Edward Medical University, Lahore, Pakistan; Department of Medicine, King Edward Medical University, Lahore, Pakistan.
| | - Arsalan Ali Khan
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | | | - Abdullah Ali Khan
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | - Amna Khalid
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Abia Shahid
- Department of Cardiology, King Edward Medical University, Lahore, Pakistan; Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | | | - Ali Syed
- Medical College of Wisconsin, Milwaukee, WI
| | - Neha Bansal
- Division of Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, New York, NY
| | - Koichi Yuki
- Cardiac Anesthesia Division, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia and Immunology, Harvard Medical School, Boston, MA
| | - Sunil J Ghelani
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sourbha S Dani
- Division of Cardiovascular Medicine, Beth Israel Lahey Health, Lahey Hospital and Medical Center, Burlington, MA
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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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Fields JT, O’Halloran CP, Tannous P, Karolcik BA, Bradley SM, Kavarana MN, Rhodes JF, Graham EM, Costello JM. Differences in outcomes between surgical pericardial window and pericardiocentesis in children with postpericardiotomy syndrome. Ann Pediatr Cardiol 2023; 16:422-425. [PMID: 38817257 PMCID: PMC11135883 DOI: 10.4103/apc.apc_108_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/17/2023] [Accepted: 01/19/2024] [Indexed: 06/01/2024] Open
Abstract
Children with postpericardiotomy syndrome may develop hemodynamically significant pericardial effusions warranting drainage by surgical pericardial window or pericardiocentesis. The optimal approach is unknown. We performed a retrospective observational study at two pediatric cardiac centers. We included 42 children aged <18 years who developed postpericardiotomy syndrome following cardiac surgery between 2014 and 2021. Thirty-two patients underwent pericardial window and 10 underwent pericardiocentesis. Patients in the pericardial window group presented with postpericardiotomy syndrome sooner than those who underwent pericardiocentesis (median 7.5 days vs. 14.5 days, P = 0.03) and tended to undergo earlier intervention (median 8 days vs. 16 days, P = 0.16). No patient required subsequent drainage. There were no differences between groups in days of pericardial tube duration (median 4 days), complications, and subsequent days of intensive care or hospitalization. For children with postpericardiotomy syndrome with a pericardial effusion warranting drainage, these data suggest that pericardial window and pericardiocentesis have similar efficacy, safety, and resource utilization.
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Affiliation(s)
- Joshua T. Fields
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Conor P. O’Halloran
- Department of Pediatrics, Division of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Paul Tannous
- Department of Pediatrics, Division of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brock A. Karolcik
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Scott M. Bradley
- Department of Surgery, Section of Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Minoo N. Kavarana
- Department of Surgery, Section of Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - John F. Rhodes
- Department of Pediatrics, Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Eric M. Graham
- Department of Pediatrics, Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - John M. Costello
- Department of Pediatrics, Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
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Suieubekov B, Sepbayeva A, Yeshmanova A, Kusainov A. Cardiac surgery-associated acute kidney injury in newborns: A meta-analysis. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023. [DOI: 10.29333/ejgm/12805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
<b>Introduction</b>: Acute kidney injury is a common complication following pediatric heart surgery, and it has been linked to an increased risk of morbidity and fatality.<br />
<b>Methods</b>: The PubMed and Medline databases were combed for relevant research until May 2022. The terms [Cardiac surgery] AND [acute renal injury] AND [newborns OR children OR neonates] AND [randomized control studies OR randomized control trials] were used as search criteria. The studies that met the inclusion criteria were considered qualified using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.<br />
<b>Results</b>: A total of 2,941 newborns or children were enrolled in 14 studies, with 931 developing acute renal damage. 2,095 of the enrolled infants and children received steroid, aminophylline, dexmedetomidine, and acetaminophen therapies. In seven studies, the odds ratio for steroids was not significantly different from control. In contrast, two studies comparing aminophylline to a control group found no statistically significant change. Two studies found no significant difference in dexmedetomidine therapy compared to control. Three trials, however, found a significant difference between the acetaminophen treatment and control groups.<br />
<b>Conclusion</b>: Acetaminophen was linked to a decreased risk of postoperative acute renal injury, while steroids had no benefit and aminophylline treatment could be justified.
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Affiliation(s)
| | - Anar Sepbayeva
- Asfendiyarov Kazakh National Medical University, Almaty, KAZAKHSTAN
| | - Ainur Yeshmanova
- Asfendiyarov Kazakh National Medical University, Almaty, KAZAKHSTAN
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Kumar A, Ghotra GS, Dwivedi D, Bhargava DV, Joshi A, Tiwari N, Ramamurthy HR. Common Inflammatory Markers and Outcome After Pediatric Cardiac Surgery With High Thoracic Epidural Anesthesia: A Randomized Controlled Study. World J Pediatr Congenit Heart Surg 2023; 14:334-344. [PMID: 36823972 DOI: 10.1177/21501351221151053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Background: High thoracic epidural analgesia (HTEA) plays a pivotal role in reducing stress and neuroendocrine response in cardiac surgeries. Aim: The primary objective is to assess the effect of HTEA, in pediatric cardiac surgery, on inflammatory markers (interleukin [IL]-6, IL-8, and tumor necrosis factor-α). The secondary objectives are to assess its effect on various organ systems, that is, pulmonary (PaO2, P/F ratio), renal (Creatinine clearance, somatic near infrared spectroscopy [NIRS], serum neutrophil gelatinase-associated lipocalin values), cardiac (cardiac index, serum Trop-I, and lactate levels), mechanical ventilation duration, and length of stay in hospital (LOS). Methods: The study included 188 pediatric patients, who underwent, on-pump cardiac surgery randomized into the Epidural Group (n = 92) and Non-Epidural Group (n = 96). After general anesthesia, a 23 G epidural catheter was placed at the T4-5 level with a Bupivacaine infusion while the Non-epidural Group received fentanyl infusion. Blood samples were collected at four-time points, T0(preop), T1(4 h), and on the first and second postoperative days (T2 and T3). Results: The inflammatory markers were reduced, while the outcomes variables of mechanical ventilation (MV) duration had lower values in the epidural group (19.5 h vs 47.3 h, P = .002). LOS was shorter (10.1 days vs 13.3 days, P = .016). pO2, PF ratio, and renal NIRS values were better in the Epidural Gp, while other parameters were comparable. Non-epidural Gp had more complications esp. Acute kidney injury requires RRT. Conclusion: HTEA use in pediatric, on-pump cardiac surgery offers a favorable profile in terms of reduction in the inflammatory markers and positive effect on the organ systems with lesser MV duration and the LOS.
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Affiliation(s)
- Alok Kumar
- Department of Anaesthesia & Critical Care, 521937Army Hospital (Research & Referral), New Delhi, India
| | - Gurpinder Singh Ghotra
- Department of Anaesthesia & Critical Care, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Deepak Dwivedi
- Department of Anaesthesia & Critical Care, Department of Anaesthesia & Critical Care, 30154Command Hospital (Eastern command), Kolkata, India
| | - D V Bhargava
- Department of Anaesthesia & Critical Care, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Ankur Joshi
- Department of Anaesthesia & Critical Care, 521937Army Hospital (Research & Referral), New Delhi, India
| | - Nikhil Tiwari
- Department of Cardiothoracic Surgery, 521937Army Hospital (Research & Referral), New Delhi, India
| | - H R Ramamurthy
- Department of Paediatrics, 521937Army Hospital (Research & Referral), New Delhi, India
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Saeed H, Abdelrahim ME. A meta-analysis of pharmacological treatments for preventing acute renal injury after juvenile heart surgery. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Chen L, Xiang F, Hu Y. Corticosteroids in patients undergoing cardiac surgery: A meta-analysis of 12,559 patients. Perfusion 2022; 38:853-859. [PMID: 35657725 DOI: 10.1177/02676591221106324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Corticosteroids can attenuate the inflammatory response to cardiopulmonary bypass, but their benefits on clinical outcomes are unclear. We conducted a meta-analysis to evaluate whether corticosteroid therapy affects outcomes in patients undergoing cardiac surgery. METHODS We searched PubMed, Embase, EBSCO and Cochrane databases from 1 January 2010 to 14 March 2022 for randomized controlled trials (RCTs) that assessed corticosteroid versus non- corticosteroid therapy in patients undergoing cardiac surgery. The primary outcome was in-hospital mortality. Secondary outcomes were renal failure, infection, delirium, intensive care unit (ICU) and hospital stay. RESULTS Four RCTs including 12,559 patients (6265 randomized to corticosteroid therapy and 6294 to non-corticosteroid therapy) were included. One-hundred and 92 of 6265 patients (3.1%) randomized to the corticosteroid group versus 221 of 6294 patients (3.5%) randomized to the non-corticosteroid group experienced death during hospitalization. Compared the control group, corticosteroid therapy did not significantly reduce in-hospital mortality, with an RR of 0.87 (0.72-1.06), p = .16. There was no difference in the incidence of infection (RR 0.78 (0.56-1.10), p = .16), delirium during hospitalization (RR 1.01 (0.90-1.14), p = .85), or the length of hospital stay (MD -0.13 (-0.32 to 0.05), p = .17). However, corticosteroid therapy significantly reduced the risk of renal failure ( RR 0.82 (0.67-0.99), p = .04), and the length of ICU stay (MD -0.41 (-0.65 to -0.17), p < .01). CONCLUSIONS Corticosteroids did not significantly reduce the rates of in-hospital mortality, infection, or delirium, but reduce the incidence of renal failure and the length of ICU stay.
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Affiliation(s)
- Lei Chen
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Feng Xiang
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Yiyi Hu
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
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Chai T, Zhuang X, Tian M, Yang X, Qiu Z, Xu S, Cai M, Lin Y, Chen L. Meta-Analysis: Shouldn't Prophylactic Corticosteroids be Administered During Cardiac Surgery with Cardiopulmonary Bypass? Front Surg 2022; 9:832205. [PMID: 35722531 PMCID: PMC9198450 DOI: 10.3389/fsurg.2022.832205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 05/02/2022] [Indexed: 12/04/2022] Open
Abstract
Background Corticosteroids can effectively inhibit systemic inflammation induced by cardiopulmonary bypass. Recently clinical trials and meta-analyses and current guidelines for cardiac surgery do not support corticosteroids prophylaxis during cardiac surgery because of an increase in myocardial infarction and no benefit for patients. The aim of this study is to determine whether specific corticosteroids dose ranges might provide clinical benefits without increasing myocardial infarction. Methods The PubMed, Web of Science, Embase, Clinical Trials, and Cochrane databases were searched for randomized controlled trials (RCTs) published before August 1, 2021. Results 88 RCTs with 18,416 patients (17,067 adults and 1,349 children) were identified. Relative to placebo and high-dose corticosteroids, low-dose corticosteroids (≤20 mg/kg hydrocortisone) during adult cardiac surgery did not increase the risks of myocardial infarction (odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.43-2.17; p = 0.93). However, low-dose corticosteroids were associated with lower risks of atrial fibrillation (OR: 0.58, 95% CI: 0.44-0.76; p < 0.0001) and kidney injury (OR: 0.29, 95% CI: 0.09-0.96; p = 0.04). Furthermore, low-dose corticosteroids significantly shortened the mechanical ventilation times (mean difference [MD]: -2.74 h, 95% CI: -4.14, -1.33; p = 0.0001), intensive care unit (ICU) stay (MD: -1.48 days, 95% CI: -2.73, -0.22; p = 0.02), and hospital stay (MD: -2.29 days, 95% CI: -4.51, -0.07; p = 0.04). Conclusion Low-dose corticosteroids prophylaxis during cardiac surgery provided significant benefits for adult patients, without increasing the risks of myocardial infarction and other complications.
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Affiliation(s)
- Tianci Chai
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Department of anesthesiology, Xinyi People’s Hospital, Xuzhou, China
| | - Xinghui Zhuang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
| | - Mengyue Tian
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Xiaojie Yang
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, The School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhihuang Qiu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
| | - Shurong Xu
- Nursing Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Meiling Cai
- Nursing Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yanjuan Lin
- Nursing Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
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12
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Sigler M, Rouatbi H, Vazquez-Jimenez J, Seghaye MC. Uni-ventricular palliation vs. bi-ventricular repair: differential inflammatory response. Mol Cell Pediatr 2022; 9:5. [PMID: 35307783 PMCID: PMC8934903 DOI: 10.1186/s40348-022-00138-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background To examine whether uni-ventricular palliation (UVP) and bi-ventricular repair (BVR) result in a different pattern of systemic inflammatory response to pediatric cardiac surgery with extra-corporeal circulation (ECC). Methods In 20 children (median age 39.5 months) undergoing either UVP (n = 12) or BVR (n = 8), plasma levels of the inflammatory cytokines TNF-α, IL-6, IL-10, and IL-12 and of procalcitonin (PCT), were measured before, during and after open cardiac surgery up to postoperative day (POD) 10. Results Epidemiologic, operative- and outcome variables were similar in both groups but post-operative central venous pressure that was higher in UVP. In the whole cohort, the inflammatory response was characterized by an early important, significant and parallel increase of IL-6 and IL-10 that reached their peak values either at the end of ECC (IL-10) or 4 h postoperatively (IL-6), respectively and by a significant and parallel decrease of TNF-α and IL-12 levels after connection to ECC, followed by a bi-phasic significant increase with a first peak 4 h after ECC and a second at POD 10, respectively. Patients after UVP showed a shift of the cytokine balance with lower IL-6- (p = 0.01) after connection to ECC, lower early post-operative TNF-α - (p = 0.02) and IL-12- (p = 0.04) concentrations and lower TNF-α/IL-10-ratio (p = 0.03) as compared with patients with BVR. Levels of PCT were similar in both groups. Conclusions UVP is associated with an anti-inflammatory shift of the inflammatory response to cardiac surgery that might be related to the particular hemodynamic situation of patients with UVP.
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Affiliation(s)
- Matthias Sigler
- Pediatric Cardiology, Intensive Care Medicine and Neonatology, Georg-August Universität, Robert-Koch-Str. 40, D-37075, Göttingen, Germany.
| | - Hatem Rouatbi
- Department of Pediatrics and Pediatric Cardiology, University Hospital Liège, Liège, Belgium
| | - Jaime Vazquez-Jimenez
- Department of Pediatric Cardiac Surgery, University Hospital Aachen, Aachen, Germany
| | - Marie-Christine Seghaye
- Department of Pediatrics and Pediatric Cardiology, University Hospital Liège, Liège, Belgium
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13
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Kobayashi K, Liu C, Jonas RA, Ishibashi N. The Current Status of Neuroprotection in Congenital Heart Disease. CHILDREN 2021; 8:children8121116. [PMID: 34943311 PMCID: PMC8700367 DOI: 10.3390/children8121116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022]
Abstract
Neurological deficits are a serious and common sequelae of congenital heart disease (CHD). While their underlying mechanisms have not been fully characterized, their manifestations are well-known and understood to persist through adulthood. Development of therapies to address or prevent these deficits are critical to attenuate future morbidity and improve quality of life. In this review, we aim to summarize the current status of neuroprotective therapy in CHD. Through an exploration of present research in the pre-operative, intra-operative, and post-operative phases of patient management, we will describe existing clinical and bench efforts as well as current endeavors underway within this research area.
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Affiliation(s)
- Kei Kobayashi
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC 20010, USA
| | - Christopher Liu
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Richard A. Jonas
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC 20010, USA
- School of Medicine and Health Science, George Washington University, Washington, DC 20052, USA
| | - Nobuyuki Ishibashi
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC 20010, USA
- School of Medicine and Health Science, George Washington University, Washington, DC 20052, USA
- Correspondence:
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14
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Van den Eynde J, Cloet N, Van Lerberghe R, Sá MPB, Vlasselaers D, Toelen J, Verbakel JY, Budts W, Gewillig M, Kutty S, Pottel H, Mekahli D. Strategies to Prevent Acute Kidney Injury after Pediatric Cardiac Surgery: A Network Meta-Analysis. Clin J Am Soc Nephrol 2021; 16:1480-1490. [PMID: 34620647 PMCID: PMC8498996 DOI: 10.2215/cjn.05800421] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/30/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES AKI is a common complication after pediatric cardiac surgery and has been associated with higher morbidity and mortality. We aimed to compare the efficacy of available pharmacologic and nonpharmacologic strategies to prevent AKI after pediatric cardiac surgery. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS PubMed/MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists of relevant articles were searched for randomized controlled trials from inception until August 2020. Random effects traditional pairwise, Bayesian network meta-analyses, and trial sequential analyses were performed. RESULTS Twenty randomized controlled trials including 2339 patients and 11 preventive strategies met the eligibility criteria. No overall significant differences were observed compared with control for corticosteroids, fenoldopam, hydroxyethyl starch, or remote ischemic preconditioning in traditional pairwise meta-analysis. In contrast, trial sequential analysis suggested a 80% relative risk reduction with dexmedetomidine and evidence of <57% relative risk reduction with remote ischemic preconditioning. Nonetheless, the network meta-analysis was unable to demonstrate any significant differences among the examined treatments, including also acetaminophen, aminophylline, levosimendan, milrinone, and normothermic cardiopulmonary bypass. Surface under the cumulative ranking curve probabilities showed that milrinone (76%) was most likely to result in the lowest risk of AKI, followed by dexmedetomidine (70%), levosimendan (70%), aminophylline (59%), normothermic cardiopulmonary bypass (57%), and remote ischemic preconditioning (55%), although all showing important overlap. CONCLUSIONS Current evidence from randomized controlled trials does not support the efficacy of most strategies to prevent AKI in the pediatric population, apart from limited evidence for dexmedetomidine and remote ischemic preconditioning.
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Affiliation(s)
- Jef Van den Eynde
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, Maryland
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Nicolas Cloet
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Michel Pompeu B.O. Sá
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco–PROCAPE, University of Pernambuco–UPE, Recife, Brazil
| | - Dirk Vlasselaers
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jaan Toelen
- Division of Woman and Child, Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jan Y. Verbakel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Werner Budts
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Marc Gewillig
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Shelby Kutty
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, Maryland
| | - Hans Pottel
- Department of Public Health and Primary Care, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Djalila Mekahli
- Department of Pediatric Nephrology, University Hospitals of Leuven, Leuven, Belgium
- PKD Research Group, GPURE, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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15
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The Role of Deep Hypothermia in Cardiac Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137061. [PMID: 34280995 PMCID: PMC8297075 DOI: 10.3390/ijerph18137061] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 12/24/2022]
Abstract
Hypothermia is defined as a decrease in body core temperature to below 35 °C. In cardiac surgery, four stages of hypothermia are distinguished: mild, moderate, deep, and profound. The organ protection offered by deep hypothermia (DH) enables safe circulatory arrest as a prerequisite to carrying out cardiac surgical intervention. In adult cardiac surgery, DH is mainly used in aortic arch surgery, surgical treatment of pulmonary embolism, and acute type-A aortic dissection interventions. In surgery treating congenital defects, DH is used to assist aortic arch reconstructions, hypoplastic left heart syndrome interventions, and for multi-stage treatment of infants with a single heart ventricle during the neonatal period. However, it should be noted that a safe duration of circulatory arrest in DH for the central nervous system is 30 to 40 min at most and should not be exceeded to prevent severe neurological adverse events. Personalized therapy for the patient and adequate blood temperature monitoring, glycemia, hematocrit, pH, and cerebral oxygenation is a prerequisite and indispensable part of DH.
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16
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Zyblewski SC, Martin RH, Shipes VB, Hamlin-Smith K, Atz AM, Bradley SM, Kavarana MN, Mahle WT, Everett AD, Graham EM. Intraoperative methylprednisolone and neurodevelopmental outcomes in infants after cardiac surgery. Ann Thorac Surg 2021; 113:2079-2084. [PMID: 33864754 DOI: 10.1016/j.athoracsur.2021.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/03/2021] [Accepted: 04/05/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Neurodevelopmental impairment is a significant consequence for survivors of surgery for critical congenital heart disease. This study sought to determine if intraoperative methylprednisolone during neonatal cardiac surgery is associated with neurodevelopmental outcomes at 12 months of age and to identify early prognostic variables associated with neurodevelopmental outcomes. METHODS A planned secondary analysis of a two-center, double-blind, randomized, placebo-controlled trial of intraoperative methylprednisolone in neonates undergoing cardiac surgery was performed. A brain injury biomarker was measured perioperatively. Bayley Scales of Infant and Toddler Development-III (BSID-III) were performed at 12 months of age. Two sample t-tests and generalized linear models were used. RESULTS There were 129 participants (n=61 methylprednisolone, n=68 placebo). There were no significant differences in BSID-III scores and brain injury biomarker levels between the two treatment groups. Participants who underwent a palliative (vs. corrective) procedure had lower mean BSID-III cognitive (101+15 vs. 106+14, p=0.03) and motor scores (85+18 vs. 94+16, p<0.01). Longer ventilation time was associated with lower motor scores. Longer cardiac intensive care unit (CICU) stay was associated with lower cognitive, language, and motor scores. Cardiopulmonary bypass time, aortic cross clamp time, and deep hypothermic circulatory arrest were not associated with BSID-III scores. CONCLUSIONS Neurodevelopmental outcomes were not associated with intraoperative methylprednisolone or intraoperative variables. Participants who underwent a neonatal palliative (vs. corrective) procedure had longer CICU stays and worse neurodevelopmental outcomes at 1 year. This work suggests that interventions focused solely on the operative period may not be associated with a long-term neurodevelopmental benefit.
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Affiliation(s)
- Sinai C Zyblewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC.
| | - Reneé H Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Virginia B Shipes
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Kasey Hamlin-Smith
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Scott M Bradley
- Section of Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC
| | - Minoo N Kavarana
- Section of Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC
| | - William T Mahle
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA
| | - Allen D Everett
- Department of Pediatrics, The Johns Hopkins University, Baltimore, MD
| | - Eric M Graham
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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He J, Zhang Y, Qiu Z, Chai T, Fang G, Hu Y, Xu F, Huang Q, Zheng H, Zhou H, Tian M, Chen LW. Efficacy and safety of corticosteroids prophylaxis in cardiac surgery: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23240. [PMID: 33327245 PMCID: PMC7738078 DOI: 10.1097/md.0000000000023240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/19/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Although corticosteroid prophylaxis in adult cardiac surgery has been studied extensively for 40 years, its role remains controversial, and the optimal dose remains uncertain. The objective of this meta-analysis was to estimate the clinical benefits and risks of corticosteroid use in cardiopulmonary bypass. METHODS We will search Pubmed, Web of Science, Embase, Clinical Trials, and Cochrane Central Register of Controlled Trials for relevant clinical trials published in any language before August 1, 2020. Randomized controlled trials (RCTs) of interest which meet inclusion criteria published or unpublished will be included. We will divide the included studies into child and adult groups for analysis. If sufficient data are available, the included trials will be divided into 4 subgroups: ≤20 mg/kg (low dose), 20-40 mg/kg (slightly high dose), 40-100 mg/kg (high dose), and >100 mg/kg (ultra high dose) based on the equivalent hydrocortisone dose. INPLASY registration number: INPLASY2020100044. RESULTS The results of this study will be published in a peer-reviewed journal. CONCLUSION This study will compare the efficacy of tprophylactic corticosteroids for adults and children undergoing cardiac surgery with CPB. Due to the nature of the disease and intervention methods, randomized controlled trials may be inadequate, and we will carefully consider inclusion in high-quality, non-randomized controlled trials, but this may result in high heterogeneity and affect the reliability of the results.
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Affiliation(s)
- Jian He
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou
| | - Yuling Zhang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou
| | - Zhihuang Qiu
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou
| | - Tianci Chai
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou
| | - Guanhua Fang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou
| | - Yunnan Hu
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou
| | - Fan Xu
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou
| | - Qiuyu Huang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou
| | - Hui Zheng
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou
| | - Hao Zhou
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou
| | - Mengyue Tian
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Liang Wan Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou
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18
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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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20
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Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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21
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Lomivorotov V, Kornilov I, Boboshko V, Shmyrev V, Bondarenko I, Soynov I, Voytov A, Polyanskih S, Strunin O, Bogachev-Prokophiev A, Landoni G, Nigro Neto C, Oliveira Nicolau G, Saurith Izquierdo L, Nogueira Nascimento V, Wen Z, Renjie H, Haibo Z, Bazylev V, Evdokimov M, Sulejmanov S, Chernogrivov A, Ponomarev D. Effect of Intraoperative Dexamethasone on Major Complications and Mortality Among Infants Undergoing Cardiac Surgery: The DECISION Randomized Clinical Trial. JAMA 2020; 323:2485-2492. [PMID: 32573670 PMCID: PMC7312411 DOI: 10.1001/jama.2020.8133] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Corticosteroids are widely used in pediatric cardiac surgery to blunt systemic inflammatory response and to reduce complications; nevertheless, their clinical efficacy is uncertain. OBJECTIVE To determine whether intraoperative administration of dexamethasone is more effective than placebo for reducing major complications and mortality during pediatric cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS The Intraoperative Dexamethasone in Pediatric Cardiac Surgery was an investigator-initiated, double-blind, multicenter randomized trial that involved 4 centers in China, Brazil, and Russia. A total of 394 infants younger than 12 months, undergoing cardiac surgery with cardiopulmonary bypass were enrolled from December 2015 to October 2018, with follow-up completed in November 2018. INTERVENTIONS The dexamethasone group (n = 194) received 1 mg/kg of dexamethasone; the control group (n = 200) received an equivolume of 0.9% sodium chloride intravenously after anesthesia induction. MAIN OUTCOMES AND MEASURES The primary end point was a composite of death, nonfatal myocardial infarction, need for extracorporeal membrane oxygenation, need for cardiopulmonary resuscitation, acute kidney injury, prolonged mechanical ventilation, or neurological complications within 30 days after surgery. There were 17 secondary end points, including the individual components of the primary end point, and duration of mechanical ventilation, inotropic index, intensive care unit stay, readmission to intensive care unit, and length of hospitalization. RESULTS All of the 394 patients randomized (median age, 6 months; 47.2% boys) completed the trial. The primary end point occurred in 74 patients (38.1%) in the dexamethasone group vs 91 patients (45.5%) in the control group (absolute risk reduction, 7.4%; 95% CI, -0.8% to 15.3%; hazard ratio, 0.82; 95% CI, 0.60 to 1.10; P = .20). Of the 17 prespecified secondary end points, none showed a statistically significant difference between groups. Infections occurred in 4 patients (2.0%) in the dexamethasone group vs 3 patients (1.5%) in the control group. CONCLUSIONS AND RELEVANCE Among infants younger than 12 months undergoing cardiac surgery with cardiopulmonary bypass, intraoperative administration of dexamethasone, compared with placebo, did not significantly reduce major complications and mortality at 30 days. However, the study may have been underpowered to detect a clinically important difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02615262.
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Affiliation(s)
- Vladimir Lomivorotov
- E. N. Meshalkin National Medical Research Center, Novosibirsk, Russia
- Novosibirsk State University, Novosibirsk, Russia
| | - Igor Kornilov
- E. N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Vladimir Boboshko
- E. N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Vladimir Shmyrev
- E. N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Ilya Bondarenko
- E. N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Ilya Soynov
- E. N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Alexey Voytov
- E. N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | | | - Oleg Strunin
- E. N. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | | | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | | | | | | | | | - Zhang Wen
- Shanghai Jiaotong University School of Medicine, Shanghai Children's Medical Center, Shanghai Shi, China
| | - Hu Renjie
- Shanghai Jiaotong University School of Medicine, Shanghai Children's Medical Center, Shanghai Shi, China
| | - Zhang Haibo
- Shanghai Jiaotong University School of Medicine, Shanghai Children's Medical Center, Shanghai Shi, China
| | - Vladlen Bazylev
- Federal Centre of Cardiovascular Surgery, Penza, Russian Federation
| | | | | | | | - Dmitry Ponomarev
- E. N. Meshalkin National Medical Research Center, Novosibirsk, Russia
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22
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Graham EM, Martin RH, Buckley JR, Zyblewski SC, Kavarana MN, Bradley SM, Alsoufi B, Mahle WT, Hassid M, Atz AM. Corticosteroid Therapy in Neonates Undergoing Cardiopulmonary Bypass: Randomized Controlled Trial. J Am Coll Cardiol 2020; 74:659-668. [PMID: 31370958 DOI: 10.1016/j.jacc.2019.05.060] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The efficacy of intraoperative corticosteroids to improve outcomes following congenital cardiac operations remains controversial. OBJECTIVES The purpose of this study was to determine whether intraoperative methylprednisolone improves post-operative recovery in neonates undergoing cardiac surgery. METHODS Neonates undergoing cardiac surgery with cardiopulmonary bypass at 2 centers were enrolled in a double-blind randomized controlled trial of methylprednisolone (30 mg/kg) or placebo after the induction of anesthesia. The primary outcome was a previously validated morbidity-mortality composite that included any of the following events following surgery before discharge: death, mechanical circulatory support, cardiac arrest, hepatic injury, renal injury, or rising lactate level (>5 mmol/l). RESULTS Of the 190 subjects enrolled, 176 (n = 81 methylprednisolone, n = 95 placebo) were included in this analysis. A total of 27 (33%) subjects in the methylprednisolone group and 40 (42%) in the placebo group reached the primary study endpoint (odds ratio [OR]: 0.63; 95% confidence interval [CI]: 0.31 to 1.3; p = 0.21). Methylprednisolone was associated with reductions in vasoactive inotropic requirements and in the incidence of the composite endpoint in subjects undergoing palliative operations (OR: 0.38; 95% CI: 0.15 to 0.99; p = 0.048). There was a significant interaction between treatment effect and center. In this analysis, methylprednisolone was protective at 1 center, with an OR: 0.35 (95% CI: 0.15 to 0.84; p = 0.02), and not so at the other center, with OR: 5.13 (95% CI: 0.85 to 30.90; p = 0.07). CONCLUSIONS Intraoperative methylprednisolone failed to show an overall significant benefit on the incidence of the composite primary study endpoint. There was, however, a benefit in patients undergoing palliative procedures and a significant interaction between treatment effect and center, suggesting that there may be center or patient characteristics that make prophylactic methylprednisolone beneficial.
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Affiliation(s)
- Eric M Graham
- Medical University of South Carolina, Charleston, South Carolina.
| | - Reneé H Martin
- Medical University of South Carolina, Charleston, South Carolina
| | - Jason R Buckley
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Minoo N Kavarana
- Medical University of South Carolina, Charleston, South Carolina
| | - Scott M Bradley
- Medical University of South Carolina, Charleston, South Carolina
| | - Bahaaldin Alsoufi
- Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | - William T Mahle
- Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | - Marc Hassid
- Medical University of South Carolina, Charleston, South Carolina
| | - Andrew M Atz
- Medical University of South Carolina, Charleston, South Carolina
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23
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Schwartz SM. Corticosteroids for Congenital Heart Surgery: When Is a Negative Trial Not a Negative Trial? J Am Coll Cardiol 2020; 74:669-671. [PMID: 31370959 DOI: 10.1016/j.jacc.2019.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Steven M Schwartz
- Departments of Critical Care Medicine and Paediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada.
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24
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Hill KD, Baldwin HS, Bichel DP, Butts RJ, Chamberlain RC, Ellis AM, Graham EM, Hickerson J, Hornik CP, Jacobs JP, Jacobs ML, Jaquiss RDB, Kannankeril PJ, O'Brien SM, Torok R, Turek JW, Li JS, Van Bergen AH, Wald E, Resheidat A, Vener DF, Jaggers J, Kumar SR, St. Louis J, Hammel J, Overman D, Blasiole B, Scott JP, Benscoter AL, Karamlou T, Ravekes WJ, Ofori-Amanfo G, Buckley JR, Zyblewski SC, McConnell P, Anderson BR, Santana-Acosta D, Eghtesady P, Bleiweis M, Swartz M, Butts RJ, Husain SA, Lambert L, Amula V, Eckhauser R, Griffiths E, Williams R, Witte M, Minich L. Rationale and design of the STeroids to REduce Systemic inflammation after infant heart Surgery (STRESS) trial. Am Heart J 2020; 220:192-202. [PMID: 31855716 PMCID: PMC7008076 DOI: 10.1016/j.ahj.2019.11.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 11/27/2019] [Indexed: 11/25/2022]
Abstract
For decades, physicians have administered corticosteroids in the perioperative period to infants undergoing heart surgery with cardiopulmonary bypass (CPB) to reduce the postoperative systemic inflammatory response to CPB. Some question this practice because steroid efficacy has not been conclusively demonstrated and because some studies indicate that steroids could have harmful effects. STRESS is a randomized, placebo-controlled, double-blind, multicenter trial designed to evaluate safety and efficacy of perioperative steroids in infants (age < 1 year) undergoing heart surgery with CPB. Participants (planned enrollment = 1,200) are randomized 1:1 to methylprednisolone (30 mg/kg) administered into the CPB pump prime versus placebo. The trial is nested within the existing infrastructure of the Society of Thoracic Surgeons Congenital Heart Surgery Database. The primary outcome is a global rank score of mortality, major morbidities, and hospital length of stay with components ranked commensurate with their clinical severity. Secondary outcomes include several measures of major postoperative morbidity, postoperative hospital length of stay, and steroid-related safety outcomes including prevalence of hyperglycemia and postoperative infectious complications. STRESS will be one of the largest trials ever conducted in children with heart disease and will answer a decades-old question related to safety and efficacy of perioperative steroids in infants undergoing heart surgery with CPB. The pragmatic "trial within a registry" design may provide a mechanism for conducting low-cost, high-efficiency trials in a heretofore-understudied patient population.
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25
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Li Y, Luo Q, Wu X, Jia Y, Yan F. Perioperative Corticosteroid Therapy in Children Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis. Front Pediatr 2020; 8:350. [PMID: 32903325 PMCID: PMC7396528 DOI: 10.3389/fped.2020.00350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 05/27/2020] [Indexed: 11/25/2022] Open
Abstract
Background: The benefit-risk profile of perioperative corticosteroids in pediatric patients undergoing cardiac surgery remains controversial. Objective: To investigate the influence of perioperative corticosteroids on the postoperative mortality and clinical outcomes in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: We conducted a systematic search using MEDLINE, EMBASE, and Cochrane Database through August 31, 2019. We included randomized controlled trials comparing perioperative corticosteroids with other clinical interventions, placebo, or no treatment in children between 0 and 18 years of age undergoing cardiac surgery. The primary outcome of interest was all-cause in-hospital mortality. The secondary outcomes were length of intensive care unit stay (LOIS), duration of mechanical ventilation (DMV), postoperative insulin therapy, postoperative low cardiac output syndrome (LCOS), postoperative infection, maximal temperature (T max) in the first 24 h postoperatively, urine output (UO) in the first 24 h postoperatively, serum lactate at postoperative day (POD) 1, blood glucose at POD 1, vasoactive inotrope score (VIS) at POD 1, and postoperative acute kidney injury (AKI). Study quality was assessed using the Cochrane Risk of Bias Assessment Tool. Results: Our analysis included 17 studies and 848 pediatric patients. The data demonstrated that children receiving corticosteroids showed no significant difference on the all-cause in-hospital mortality with a fixed-effect model (RR = 0.59, 95% CI = 0.28-1.25, P = 0.55) compared with controls. For the secondary outcomes, corticosteroids had a statistically significant reduction on the VIS at POD1 (MD = -2.04, 95% CI = -3.96 -0.12, P = 0.04), while it might be significantly associated with an increased blood glucose at POD1 (MD = 1.38, 95% CI = 0.68-2.09, P = 0.0001) and a 2.69-fold higher risk of postoperative insulin therapy (RR = 2.69, 95% CI = 1.37-5.27, P = 0.004). No statistical significance was shown in other secondary outcomes. Conclusion: Perioperative corticosteroids might not significantly improve clinical outcomes identified as mortality, LOIS, DMV, AKI, and LCOS other than VIS at POD1. However, it might increase the blood glucose and episodes of insulin therapy. Perioperative corticosteroids to attenuate the inflammatory response are not supported by available evidence from our study. Further results from ongoing randomized controlled trials with a larger sample size are required.
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Affiliation(s)
- Yinan Li
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qipeng Luo
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xie Wu
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Jia
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuxia Yan
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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26
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Carlisle MA, Soranno DE, Basu RK, Gist KM. Acute Kidney Injury and Fluid Overload in Pediatric Cardiac Surgery. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2019; 5:326-342. [PMID: 33282633 PMCID: PMC7717109 DOI: 10.1007/s40746-019-00171-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) and fluid overload affect a large number of children undergoing cardiac surgery, and confers an increased risk for adverse complications and outcomes including death. Survivors of AKI suffer long-term sequelae. The purpose of this narrative review is to discuss the short and long-term impact of cardiac surgery associated AKI and fluid overload, currently available tools for diagnosis and risk stratification, existing management strategies, and future management considerations. RECENT FINDINGS Improved risk stratification, diagnostic prediction tools and clinically available early markers of tubular injury have the ability to improve AKI-associated outcomes. One of the major challenges in diagnosing AKI is the diagnostic imprecision in serum creatinine, which is impacted by a variety of factors unrelated to renal disease. In addition, many of the pharmacologic interventions for either AKI prevention or treatment have failed to show any benefit, while peritoneal dialysis catheters, either for passive drainage or prophylactic dialysis may be able to mitigate the detrimental effects of fluid overload. SUMMARY Until novel risk stratification and diagnostics tools are integrated into routine practice, supportive care will continue to be the mainstay of therapy for those affected by AKI and fluid overload after pediatric cardiac surgery. A viable series of preventative measures can be taken to mitigate the risk and severity of AKI and fluid overload following cardiac surgery, and improve care.
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Affiliation(s)
- Michael A Carlisle
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
| | - Danielle E. Soranno
- Department of Pediatrics, Division of Pediatric Nephrology, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
| | - Rajit K Basu
- Department of Pediatrics, Division of Pediatric Critical Care, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta GA
| | - Katja M Gist
- Department of Pediatrics, Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
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27
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Schlapbach LJ, Horton SB, Long DA, Beca J, Erickson S, Festa M, d’Udekem Y, Alphonso N, Winlaw D, Johnson K, Delzoppo C, van Loon K, Gannon B, Fooken J, Blumenthal A, Young P, Jones M, Butt W, Schibler A. Study protocol: NITric oxide during cardiopulmonary bypass to improve Recovery in Infants with Congenital heart defects (NITRIC trial): a randomised controlled trial. BMJ Open 2019; 9:e026664. [PMID: 31420383 PMCID: PMC6701583 DOI: 10.1136/bmjopen-2018-026664] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Congenital heart disease (CHD) is a major cause of infant mortality. Many infants with CHD require corrective surgery with most operations requiring cardiopulmonary bypass (CPB). CPB triggers a systemic inflammatory response which is associated with low cardiac output syndrome (LCOS), postoperative morbidity and mortality. Delivery of nitric oxide (NO) into CPB circuits can provide myocardial protection and reduce bypass-induced inflammation, leading to less LCOS and improved recovery. We hypothesised that using NO during CPB increases ventilator-free days (VFD) (the number of days patients spend alive and free from invasive mechanical ventilation up until day 28) compared with standard care. Here, we describe the NITRIC trial protocol. METHODS AND ANALYSIS The NITRIC trial is a randomised, double-blind, controlled, parallel-group, two-sided superiority trial to be conducted in six paediatric cardiac surgical centres. One thousand three-hundred and twenty infants <2 years of age undergoing cardiac surgery with CPB will be randomly assigned to NO at 20 ppm administered into the CPB oxygenator for the duration of CPB or standard care (no NO) in a 1:1 ratio with stratification by age (<6 and ≥6 weeks), single ventricle physiology (Y/N) and study centre. The primary outcome will be VFD to day 28. Secondary outcomes include a composite of LCOS, need for extracorporeal membrane oxygenation or death within 28 days of surgery; length of stay in intensive care and in hospital; and, healthcare costs. Analyses will be conducted on an intention-to-treat basis. Preplanned secondary analyses will investigate the impact of NO on host inflammatory profiles postsurgery. ETHICS AND DISSEMINATION The study has ethical approval (HREC/17/QRCH/43, dated 26 April 2017), is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12617000821392) and commenced recruitment in July 2017. The primary manuscript will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ACTRN12617000821392.
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Affiliation(s)
- Luregn J Schlapbach
- Paediatric Critical Care Research Group, Child Health Research Institute, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - Stephen Brian Horton
- Cardiac Surgical Unit, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Debbie Amanda Long
- Paediatric Critical Care Research Group, Child Health Research Institute, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - John Beca
- Paediatric Intensive Care Unit, Starship Children’s Hospital, Auckland, New Zealand
| | - Simon Erickson
- Paediatric Critical Care, Perth Children’s Hospital, Western Australia and The University of Western Australia, Crawley, Western Australia, Australia
| | - Marino Festa
- Kids Critical Care Research, Paediatric Intensive Care Unit, Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network, Sydney, New South Wales, Australia
| | - Yves d’Udekem
- Department of Cardiac Surgery, Royal Children’s Hospital, Melbourne, Victoria, Australia
- Heart Research, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- School of Medicine, Children’s Health Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - Nelson Alphonso
- Cardiac Surgery, Queensland Children’s Hospital, Brisbane, Queensland, Australia
| | - David Winlaw
- Heart Centre for Children, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Children’s Hospital Network and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kerry Johnson
- Paediatric Critical Care Research Group, Child Health Research Institute, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - Carmel Delzoppo
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
| | - Kim van Loon
- Division of Anaesthetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B Gannon
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Jonas Fooken
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Antje Blumenthal
- The Infection and Inflammation Group, The University of Queensland Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia
| | - Paul Young
- The Intensive Care Research Programme, Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Mark Jones
- School of Public Health, Bond University, Gold Coast, Brisbane, Australia
| | - Warwick Butt
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Child Health Research Institute, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, Children’s Health Queensland, Brisbane, Queensland, Australia
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Crawford JH, Townsley MM. Steroids for Adult and Pediatric Cardiac Surgery: A Clinical Update. J Cardiothorac Vasc Anesth 2019; 33:2039-2045. [DOI: 10.1053/j.jvca.2018.11.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Indexed: 11/11/2022]
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29
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Guo H, Ban YH, Cha Y, An ES, Choi J, Seo DW, Park D, Choi EK, Kim YB. Comparative anti-thrombotic activity and haemorrhagic adverse effect of nattokinase and tissue-type plasminogen activator. Food Sci Biotechnol 2019; 28:1535-1542. [PMID: 31695953 DOI: 10.1007/s10068-019-00580-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 01/29/2019] [Accepted: 02/08/2019] [Indexed: 12/21/2022] Open
Abstract
Anti-thrombotic activity and safety of nattokinase, an enzyme produced by Bacillus subtilis during soybean fermentation, were investigated in comparison with tissue-type plasminogen activator (t-PA). Carotid arterial thrombosis was produced with a FeCl3-soaked paper, followed by intravenous injection of nattokinase or t-PA. Nattokinase and t-PA delayed thrombus formation, near-fully (> 90%) inhibiting at 75 and 8.5 mg/kg, respectively. As adverse effects, t-PA induced petechial haemorrhage at 10 mg/kg in the lungs and thymus, and extensive bleeding at 20 mg/kg. Nattokinase also caused pulmonary haemorrhage from 300 mg/kg. Collectively, the standard safety margins (SSMs) for t-PA and nattokinase were calculated to be 1.2 and 4.0, respectively. Combinational treatment with dexamethasone (2 mg/kg) increased the efficacy and safety of t-PA and nattokinase, widening their SSMs to 2.4 and 8.0, respectively. The results indicate that nattokinase delayed thrombus formation and dissolved thrombi, and that nattokinase could be a good candidate anti-thrombotic agent with relatively-low haemorrhagic risk.
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Affiliation(s)
- Haiyu Guo
- 1College of Veterinary Medicine and Veterinary Medical Center, Chungbuk National University, 1 Chungdaero (Gaesin-dong), Cheongju, Chungbuk 28644 Korea
| | - Young-Hwan Ban
- 1College of Veterinary Medicine and Veterinary Medical Center, Chungbuk National University, 1 Chungdaero (Gaesin-dong), Cheongju, Chungbuk 28644 Korea
| | - Yeseul Cha
- 1College of Veterinary Medicine and Veterinary Medical Center, Chungbuk National University, 1 Chungdaero (Gaesin-dong), Cheongju, Chungbuk 28644 Korea
| | - Eun Suk An
- 1College of Veterinary Medicine and Veterinary Medical Center, Chungbuk National University, 1 Chungdaero (Gaesin-dong), Cheongju, Chungbuk 28644 Korea
| | - Jieun Choi
- 1College of Veterinary Medicine and Veterinary Medical Center, Chungbuk National University, 1 Chungdaero (Gaesin-dong), Cheongju, Chungbuk 28644 Korea
| | - Da Woom Seo
- 1College of Veterinary Medicine and Veterinary Medical Center, Chungbuk National University, 1 Chungdaero (Gaesin-dong), Cheongju, Chungbuk 28644 Korea
| | - Dongsun Park
- 2Department of Biology Education, Korea National University of Education, Cheongju, Chungbuk 28173 Korea
| | - Ehn-Kyoung Choi
- 1College of Veterinary Medicine and Veterinary Medical Center, Chungbuk National University, 1 Chungdaero (Gaesin-dong), Cheongju, Chungbuk 28644 Korea
| | - Yun-Bae Kim
- 1College of Veterinary Medicine and Veterinary Medical Center, Chungbuk National University, 1 Chungdaero (Gaesin-dong), Cheongju, Chungbuk 28644 Korea
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30
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Adrenal insufficiency in neonates undergoing cardiopulmonary bypass and postoperative hypothalamic-pituitary-adrenal function after prophylactic glucocorticoids. J Perinatol 2019; 39:640-647. [PMID: 30867544 DOI: 10.1038/s41372-019-0344-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/31/2019] [Accepted: 02/06/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Determine incidence of preoperative adrenal insufficiency in neonates >35 weeks gestation with congenital heart disease undergoing cardiothoracic surgery with bypass and effects of prophylactic methylprednisolone on postoperative hypothalamic-pituitary-adrenal function and hemodynamic stability. DESIGN Prospective observational study in 36 neonates with preoperative adrenocorticotrophic hormone stimulation tests and serial total cortisol and adrenocorticotrophic hormone measurements before and after surgery. Data analyses: analysis of variance and regression. RESULTS Baseline circulating adrenocorticotrophic hormone and cortisol were unchanged 4-20 days postnatal (P > 0.1); however, cortisol levels rose with increasing adrenocorticotrophic hormone, P = 0.02. Ten neonates (29%) demonstrated preoperative adrenal insufficiency (∆cortisol ≤9 µg/dl); one had postoperative hemodynamic instability. Growth-restricted neonates had lower baseline cortisol, but normal stimulation tests and responded well to surgical stresses. Seventy-five percent of neonates receiving perioperative methylprednisolone demonstrated postoperative hypothalamic-pituitary-adrenal inhibition. CONCLUSION Adrenal insufficiency appears common in neonates >35 weeks gestation with congenital heart disease, but did not contribute to postoperative hemodynamic instability despite hypothalamic-pituitary-adrenal inhibition.
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Garg AX, Chan MTV, Cuerden MS, Devereaux PJ, Abbasi SH, Hildebrand A, Lamontagne F, Lamy A, Noiseux N, Parikh CR, Perkovic V, Quantz M, Rochon A, Royse A, Sessler DI, Shah PJ, Sontrop JM, Tagarakis GI, Teoh KH, Vincent J, Walsh M, Yared JP, Yusuf S, Whitlock RP. Effect of methylprednisolone on acute kidney injury in patients undergoing cardiac surgery with a cardiopulmonary bypass pump: a randomized controlled trial. CMAJ 2019; 191:E247-E256. [PMID: 30833491 PMCID: PMC6400656 DOI: 10.1503/cmaj.181644] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2019] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. METHODS We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 μmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. RESULTS Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. INTERPRETATION Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.
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Affiliation(s)
- Amit X Garg
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont.
| | - Matthew T V Chan
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Meaghan S Cuerden
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - P J Devereaux
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Seyed Hesameddin Abbasi
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Ainslie Hildebrand
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - François Lamontagne
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Andre Lamy
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Nicolas Noiseux
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Chirag R Parikh
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Vlado Perkovic
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Mackenzie Quantz
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Antoine Rochon
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Alistair Royse
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Daniel I Sessler
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Pallav J Shah
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Jessica M Sontrop
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Georgios I Tagarakis
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Kevin H Teoh
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Jessica Vincent
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Michael Walsh
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Jean-Pierre Yared
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Salim Yusuf
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Richard P Whitlock
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
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32
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Bellos I, Iliopoulos DC, Perrea DN. Pharmacological interventions for the prevention of acute kidney injury after pediatric cardiac surgery: a network meta-analysis. Clin Exp Nephrol 2019; 23:782-791. [PMID: 30734166 DOI: 10.1007/s10157-019-01706-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/24/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Acute kidney injury constitutes a major complication of cardiac surgery in pediatric patients. The present meta-analysis aims to accumulate current literature and assess the efficacy of pharmacological interventions in preventing postoperative renal dysfunction after congenital heart surgery. METHODS Literature search was conducted using Medline (1966-2018), Scopus (2004-2018), Cochrane Central Register of Controlled Trials CENTRAL (1999-2018), Clinicaltrials.gov (2008-2018), and Google Scholar (2004-2018) databases. Statistical analysis was performed with Review Manager 5.3 and R 3.4.3. RESULTS Meta-analysis included 14 studies, with a total of 2,625 patients. AKI incidence was significantly lower in the dexmedetomidine (OR 0.49, 95% CI [0.28-0.87]) and acetaminophen (OR 0.43, 94% CI [0.28-0.67]) groups, while no difference was present in patients receiving corticosteroid (OR 1.16, 95% CI [0.69-1.95]), fenoldopam (OR 0.47, 95% CI [0.22-1.02]), or aminophylline (OR 0.98, 95% CI [0.29-3.34]). Network meta-analysis proposed that dexmedetomidine had the greatest probability (44.5%) to rank first, although significant overlap with the other treatments was observed. CONCLUSIONS The present meta-analysis suggests that no firm evidence exists about the protective role of pharmacological interventions in the pediatric population. Future randomized controlled trials should clarify the effectiveness of dexmedetomidine and acetaminophen and indicate the optimal protocol to be applied, to protect renal function in the perioperative setting.
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Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, 15Β, Ag. Thoma str., 115 27, Athens, Greece.
| | - Dimitrios C Iliopoulos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, 15Β, Ag. Thoma str., 115 27, Athens, Greece
| | - Despina N Perrea
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, 15Β, Ag. Thoma str., 115 27, Athens, Greece
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Fudulu D, Lightman S, Caputo M, Angelini G. Steroids in paediatric heart surgery: eminence or evidence-based practice? Indian J Thorac Cardiovasc Surg 2018; 34:483-487. [PMID: 33060920 PMCID: PMC7525744 DOI: 10.1007/s12055-018-0670-y] [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: 01/02/2018] [Revised: 03/05/2018] [Accepted: 03/08/2018] [Indexed: 11/29/2022] Open
Abstract
Steroids in paediatric heart surgery are given prophylactically to blunt the systemic inflammatory response induced by the extracorporeal circuit and to improve clinical outcomes. However, there is an ongoing controversy about the impact of steroids on clinical outcomes after paediatric heart surgery. The hypothalamic-pituitary-adrenal axis is the primary neuroendocrine system activated during the stress of surgery. Relative adrenal insufficiency can accompany paediatric heart surgery; therefore, perioperative steroid supplementation is still administered by some centres. The studies that investigate the hypothalamic-pituitary-adrenal axis physiology during surgery have many limitations, and it is unclear how to define what is adrenal insufficiency. In this review, we focus on discussing the available evidence for steroid use in paediatric cardiac surgery.
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Affiliation(s)
- Daniel Fudulu
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK.,Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, University of Bristol, Dorothy Hodgkin Building, Bristol, UK
| | | | - Massimo Caputo
- Department of Congenital Cardiac Surgery, Bristol Children's Hospital, Bristol, UK
| | - Gianni Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK
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Jahnukainen T, Keski-Nisula J, Tainio J, Valkonen H, Pätilä T, Jalanko H, Suominen P. Efficacy of corticosteroids in prevention of acute kidney injury in neonates undergoing cardiac surgery-A randomized controlled trial. Acta Anaesthesiol Scand 2018; 62:1072-1079. [PMID: 29667173 DOI: 10.1111/aas.13134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Heart surgery requiring cardiopulmonary bypass (CPB) causes an inflammatory response which may further induce acute kidney injury (AKI). In the present randomized controlled study we evaluated whether corticosteroids can prevent CPB related AKI in neonates undergoing heart surgery. METHODS Forty neonates were randomized to receive 2 mg/kg methylprednisolone followed by hydrocortisone infusion 0.2 mg/kg/h perioperatively with tapering doses for 5 days, or placebo administered in a similar fashion. The primary outcome was the inflammatory response (plasma concentrations of interleukins 6 and 10). The correspondence of the interleukin concentrations with AKI was analysed as secondary outcome. In addition, plasma and urine neutrophil gelatinase-associated lipocalin (NGAL), plasma cystatin C, and urine kidney injury molecule-1 (KIM-1) levels were measured. RESULTS Six patients (15%) developed post-operative AKI. No significant difference in the AKI occurrence between the treatment (n = 2) and the placebo (n = 4) groups could be found (risk ratio 2.00, 95% confidence interval 0.41-9.71; P = .661) despite significant reduction in inflammatory response in the treatment group. One patient in the treatment group and two patients in the placebo group required acute peritoneal dialysis. Plasma creatinine and cystatin C or urine NGAL and KIM-1 concentrations did not differ between the treatment and the placebo group. CONCLUSIONS Significantly reduced inflammatory reaction induced by corticosteroid treatment in neonates undergoing cardiac surgery did not reduce the incidence of AKI defined by KDIGO classification or decrease the rise of AKI biomarkers.
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Affiliation(s)
- T Jahnukainen
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Keski-Nisula
- Department of Anesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Tainio
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Valkonen
- Department of Anesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - T Pätilä
- Department of Pediatric Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Jalanko
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Suominen
- Department of Anesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Ponomarev D, Boboshko V, Shmyrev V, Kornilov I, Bondarenko I, Soynov I, Voytov A, Polyanskih S, Strunin O, Bogachev A, Landoni G, Neto CN, Nicolau GO, Wen Z, Evdokimov M, Sulejmanov S, Chernogrivov A, Karaskov A, Lomivorotov V. Dexamethasone in pEdiatric Cardiac Surgery (DECiSion): Rationale and design of a randomized controlled trial. Contemp Clin Trials 2018; 72:16-19. [PMID: 30016720 DOI: 10.1016/j.cct.2018.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 06/26/2018] [Accepted: 07/12/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Dmitry Ponomarev
- Department of Anesthesia and Intensive Care, E. Meshalkin National Medical Research Center, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation.
| | - Vladimir Boboshko
- Department of Anesthesia and Intensive Care, E. Meshalkin National Medical Research Center, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation
| | - Vladimir Shmyrev
- Department of Anesthesia and Intensive Care, E. Meshalkin National Medical Research Center, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation
| | - Igor Kornilov
- Department of Anesthesia and Intensive Care, E. Meshalkin National Medical Research Center, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation
| | - Ilya Bondarenko
- Department of Anesthesia and Intensive Care, E. Meshalkin National Medical Research Center, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation
| | - Ilya Soynov
- Department of Cardiac Surgery, E. Meshalkin National Medical Research Centre, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation
| | - Alexey Voytov
- Department of Cardiac Surgery, E. Meshalkin National Medical Research Centre, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation
| | - Stanislav Polyanskih
- Department of Anesthesia and Intensive Care, E. Meshalkin National Medical Research Center, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation
| | - Oleg Strunin
- Department of Anesthesia and Intensive Care, E. Meshalkin National Medical Research Center, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation
| | - Alexander Bogachev
- Department of Cardiac Surgery, E. Meshalkin National Medical Research Centre, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy; Vita-Salute San Raffaele University, Via Olgettina 58, Milan 20132, Italy
| | - Caetano Nigro Neto
- Dante Pazzanese Institute of Cardiology, Doutor Dante Pazzanese avenue, 500 - 6 andar/COREME, 04012180 Sao Paulo, Brazil
| | - Gretel Oliveira Nicolau
- Dante Pazzanese Institute of Cardiology, Doutor Dante Pazzanese avenue, 500 - 6 andar/COREME, 04012180 Sao Paulo, Brazil
| | - Zhang Wen
- Shanghai Children's Medical Center (SCMC) Affiliated to Shanghai Jiaotong University School of Medicine, 101 Beiyuan Rd, TangQiao, Pudong Xinqu, Shanghai Shi 200000, China
| | - Mikhail Evdokimov
- Department of Anesthesia and Intensive Care, Federal Centre of Cardiovascular Surgery, 6 Stasova Street, Penza 440071, Russian Federation
| | - Shahrijar Sulejmanov
- Department of Anesthesia and Intensive Care, Federal Centre of Cardiovascular Surgery, 6 Stasova Street, Penza 440071, Russian Federation
| | - Aleksei Chernogrivov
- Department of Cardiac Surgery, Federal Centre of Cardiovascular Surgery, 6 Stasova Street, Penza 440071, Russian Federation
| | - Alexander Karaskov
- Department of Cardiac Surgery, E. Meshalkin National Medical Research Centre, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation
| | - Vladimir Lomivorotov
- Department of Anesthesia and Intensive Care, E. Meshalkin National Medical Research Center, 15 Rechkunovskaya Street, Novosibirsk 630055, Russian Federation
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36
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Leow EH, Chan YH, Ng YH, Lim JKB, Nakao M, Lee JH. Prevention of Acute Kidney Injury in Children Undergoing Cardiac Surgery: A Narrative Review. World J Pediatr Congenit Heart Surg 2018; 9:79-90. [PMID: 29310552 DOI: 10.1177/2150135117743211] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Children undergoing cardiac surgery are at risk of developing acute kidney injury (AKI). Preventing cardiac surgery-associated AKI (CS-AKI) is important as it is associated with increased early- and long-term mortality and morbidity. Targeting modifiable risk factors (eg, avoiding poor renal perfusion, nephrotoxic drugs, and fluid overload) reduces the risk of CS-AKI. There is currently no strong evidence for the routine use of pharmacological approaches (eg, aminophylline, dexmedetomidine, fenoldopam, and steroids) to prevent CS-AKI. There is robust evidence to support the role of early peritoneal dialysis as a nonpharmacologic approach to prevent CS-AKI.
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Affiliation(s)
- Esther Huimin Leow
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- 2 Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,3 Duke-NUS School of Medicine, Singapore, Singapore
| | - Yong Hong Ng
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Joel Kian Boon Lim
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Masakazu Nakao
- 4 Department of Paediatric Cardiothoracic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- 2 Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,3 Duke-NUS School of Medicine, Singapore, Singapore
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Fudulu DP, Schadenberg A, Gibbison B, Jenkins I, Lightman S, Angelini GD, Stoica S. Corticosteroids and Other Anti-Inflammatory Strategies in Pediatric Heart Surgery: A National Survey of Practice. World J Pediatr Congenit Heart Surg 2018; 9:289-293. [PMID: 29692229 DOI: 10.1177/2150135118762392] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The role of steroids to mitigate the deleterious effects of pediatric cardiopulmonary bypass (CPB) remains a matter of debate; therefore, we aimed to assess preferences in administering corticosteroids (CSs) and the use of other anti-inflammatory strategies in pediatric cardiac surgery. METHODS A 19-question survey was distributed to consultants in pediatric cardiac anesthesia from 12 centers across the United Kingdom and Ireland. RESULTS Of the 37 respondents (37/60, 62%), 24 (65%) use CSs, while 13 (35%) do not use steroids at all. We found variability within 5 (41%) of the 12 centers. Seven consultants (7/24, 29%) administer CSs in every case, while 17 administer CSs in selected cases only (17/24, 71%). There was variability in the dose of steroid administration. Almost all consultants (23/24, 96%) administer a single dose at induction, and one administers a two-dose regimen (1/24, 4%). There was variability in CS indications. Most consultants (24/37, 66%) use modified ultrafiltration at the conclusion of CPB. Fifteen consultants (15/32, 47%) report the use of aprotinin, while only 3 use heparin-coated circuits (3/24, 9%). CONCLUSIONS We found wide variability in practice in the administration of CSs for pediatric cardiac surgery, both within and between units. While most anesthetists administer CSs in at least some cases, there is no consensus on the type of steroid, the dose, and at which patient groups this should be directed. Modified ultrafiltration is still used by most of the centers. Almost half of consultants use aprotinin, while heparin-coated circuits are infrequently used.
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Affiliation(s)
- Daniel P Fudulu
- 1 Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom.,2 Henry Welcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Alvin Schadenberg
- 3 Pediatric Cardiac Anesthesia and Intensive Care, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Ben Gibbison
- 4 Cardiac Anesthesia and Intensive Care, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Ian Jenkins
- 3 Pediatric Cardiac Anesthesia and Intensive Care, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Stafford Lightman
- 2 Henry Welcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Gianni D Angelini
- 1 Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | - Serban Stoica
- 5 Department of Congenital Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
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Manetta F, Mullan CW, Catalano MA. Neuroprotective Strategies in Repair and Replacement of the Aortic Arch. Int J Angiol 2018; 27:98-109. [PMID: 29896042 PMCID: PMC5995688 DOI: 10.1055/s-0038-1649512] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Aortic arch surgery is a technical challenge, and cerebral protection during distal anastomosis is a continued topic of controversy and discussion. The physiologic effects of hypothermic arrest and adjunctive cerebral perfusion have yet to be fully defined, and the optimal strategies are still undetermined. This review highlights the historical context, physiological rationale, and clinical efficacy of various neuroprotective strategies during arch operations.
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Affiliation(s)
- Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Clancy W. Mullan
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Michael A. Catalano
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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Abstract
OBJECTIVES Pediatric cardiac intensive care continues to evolve, with rapid advances in knowledge and improvement in clinical outcomes. In the past, the Board of Directors of the Pediatric Cardiac Intensive Care Society created and subsequently updated a list of sentinel references focused on the care of critically ill children with congenital and acquired heart disease. The objective of this article is to provide clinicians with a compilation and brief summary of updated and useful references that have been published since 2012. DATA SELECTION Pediatric Cardiac Intensive Care Society members were solicited via a survey sent out between March 20, 2017, and April 28, 2017, to provide important references that have impacted clinical care. The survey was sent to approximately 523 members. Responses were received from 45 members, of which some included multiple references. DATA EXTRACTION Following review of the list of references, and removing editorials, references were compiled by the first and last author. The final list was submitted to members of the society's Research Briefs Committee, who ranked each publication. DATA SYNTHESIS Rankings were compiled and the references with the highest scores included. Research Briefs Committee members ranked the articles from 1 to 3, with one being highly relevant and should be included and 3 being less important and should be excluded. Averages were computed, and the top articles included in this article. The first (K.C.U.) and last author (K.M.G.) reviewed and developed summaries of each article. CONCLUSIONS This article contains a compilation of useful references for the critical care of children with congenital and acquired heart disease published in the last 5 years. In conjunction with the prior version of this update in 2012, this article may be used as an educational reference in pediatric cardiac intensive care.
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Hill KD, Kannankeril PJ. Perioperative Corticosteroids in Children Undergoing Congenital Heart Surgery: Five Decades of Clinical Equipoise. World J Pediatr Congenit Heart Surg 2018; 9:294-296. [PMID: 29692235 DOI: 10.1177/2150135118765876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kevin D Hill
- 1 Duke University Medical Center, Durham, NC, USA
| | - Prince J Kannankeril
- 2 Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN, USA
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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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Neutrophil Phenotype Correlates With Postoperative Inflammatory Outcomes in Infants Undergoing Cardiopulmonary Bypass. Pediatr Crit Care Med 2017; 18:1145-1152. [PMID: 29068910 DOI: 10.1097/pcc.0000000000001361] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Infants with congenital heart disease frequently require cardiopulmonary bypass, which causes systemic inflammation. The goal of this study was to determine if neutrophil phenotype and activation status predicts the development of inflammatory complications following cardiopulmonary bypass. DESIGN Prospective cohort study. SETTING Tertiary care PICU with postoperative cardiac care. PATIENTS Thirty-seven patients 5 days to 10 months old with congenital heart disease requiring cardiopulmonary bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Laboratory and clinical data collected included length of mechanical ventilation, acute kidney injury, and fluid overload. Neutrophils were isolated from whole blood at three time points surrounding cardiopulmonary bypass. Functional analyses included measurement of cell surface protein expression and nicotinamide adenine dinucleotide phosphate oxidase activity. Of all patients studied, 40.5% displayed priming of nicotinamide adenine dinucleotide phosphate oxidase activity in response to N-formyl-Met-Leu-Phe stimulation 24 hours post cardiopulmonary bypass as compared to pre bypass. Neonates who received steroids prior to bypass demonstrated enhanced priming of nicotinamide adenine dinucleotide phosphate oxidase activity at 48 hours. Patients who displayed priming post cardiopulmonary bypass were 8.8 times more likely to develop severe acute kidney injury as compared to nonprimers. Up-regulation of neutrophil surface CD11b levels pre- to postbypass occurred in 51.4% of patients, but this measure of neutrophil priming was not associated with acute kidney injury. Subsequent analyses of the basal neutrophil phenotype revealed that those with higher basal CD11b expression were significantly less likely to develop acute kidney injury. CONCLUSIONS Neutrophil priming occurs in a subset of infants undergoing cardiopulmonary bypass. Acute kidney injury was more frequent in those patients who displayed priming of nicotinamide adenine dinucleotide phosphate oxidase activity after cardiopulmonary bypass. This pilot study suggests that neutrophil phenotypic signature could be used to predict inflammatory organ dysfunction.
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Bradley SM. Invited Commentary. Ann Thorac Surg 2017; 104:1385-1387. [PMID: 28935304 DOI: 10.1016/j.athoracsur.2017.04.069] [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: 03/26/2017] [Accepted: 04/02/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Scott M Bradley
- Pediatric Cardiac Surgery, Medical University of South Carolina, CSB 424, 96 Jonathan Lucas St, Charleston, SC 29425.
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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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45
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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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Williams GD, Ramamoorthy C. Brain Monitoring and Protection During Pediatric Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2016; 11:23-33. [PMID: 17484171 DOI: 10.1177/1089253206297412] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
With advances in medical care, survival after cardiac surgery for congenital heart disease has dramatically improved, and attention is increasingly focused on longterm functional morbidities, especially neurodevelopmental outcomes, with their profound consequences to patients and society. There are multiple reasons for concern about brain injury. Some cardiac defects are associated with brain anomalies and altered cerebral blood flow regulation. Brain imaging studies have demonstrated that injury to gray and white matter is quite frequent before heart surgery in neonates. Cardiopulmonary bypass and deep hypothermic circulatory arrest are associated with shortand longer-term adverse neurologic outcome. Additional brain injury can occur during the patient's recovery from surgery. Strategies to optimize neurologic outcome continue to evolve. With new technological developments, perioperative neurologic monitoring of small children has become easier, and data suggest these modalities usefully identify adverse neurologic events and might predict outcome. Monitoring methods to be discussed include processed electroencephalography, near infrared spectroscopy, and transcranial Doppler ultrasound. Alternative perfusion techniques to deep hypothermic circulatory arrest have been developed, such as regional antegrade cerebral perfusion during cardiopulmonary bypass. Other neuroprotective strategies employed during open-heart surgery include temperature regulation, acid-base management, degree of hemodilution, blood glucose control and anti-inflammatory therapies. Evidence of the impact of these measures on neurologic outcome is examined, and deficiencies in our current understanding of neurologic function in children with congenital heart disease are identified.
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Affiliation(s)
- Glyn D Williams
- Department of Anesthesia, Stanford University Medical School, California 94305, USA.
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47
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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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48
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Poyrazoğlu HH, Duman Z, Demir Ş, Avşar MK, Atalay A, Çiftçi B, Bayraktar İ, Tor F. Investigating the Impacts of Preoperative Steroid Treatment on Tumor Necrosis Factor-Alpha and Duration of Extubation Time underwent Ventricular Septal Defect Surgery. Balkan Med J 2016; 33:158-63. [PMID: 27403384 DOI: 10.5152/balkanmedj.2016.16379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 10/20/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cardiopulmonary bypass is known to cause inflammatory events. Inflammation occurs due to many known important biological processes. Numerous mechanisms are known to be responsible for the development of inflammatory processes. Currently, there are many defined mediators as a tumor necrosis factor-α (TNF-α) playing an active role in this process. AIMS This research was to investigate the effects of pre-operative steroid use on inflammatory mediator TNF-α and on time to extubation postoperatively in ventricular septal defect patients undergoing cardiopulmonary bypass surgery. STUDY DESIGN Controlled clinical study. METHODS This study included 30 patients. These patients were assigned into two groups, each containing 15 patients. 5 micrograms/kg methylprednisolone was injected intravenously 2 hours before the surgery to Group I, whereas there was no application to the patients in Group II. TNF-α (pg/mL) level was measured in arterial blood samples obtained at four periods including: the preoperative period (Pre TNF); at the 5(th) minute of cross-clamping (Per TNF); 2 hours after termination of cardiopulmonary bypass (Post TNF); and at the postoperative 24th hours in cardiovascular surgery intensive care unit (Post 24 h TNF). RESULTS The mean cross-clamp time was 66±40 and 55±27 minutes in Group I and Group II respectively. No significant difference was found between the groups in terms of cross-clamp time (p>0.05). The mean time to extubation was 6.1±2.3 hours in Group I and 10.6±3.4 hours in Group II. Group I extubation time was significantly shorter than Group II. Group I TNF-α levels at Post TNF and Post24h TNF was lower than Group II. These differences are also statistically significant (p<0.05). CONCLUSION There is a strong indication that preoperative steroid treatment reduced the TNF-α level together with shortens duration of postoperative intubation and positively contributes to extubation in ventricular septal defect patients operated in cardiac surgery with cardiopulmonary bypass. (ClinicalTrials.gov Identifier: TCTR20150930001).
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Affiliation(s)
- H Hakan Poyrazoğlu
- Department of Cardiovascular Surgery, Çukurova University School of Medicine, Adana, Turkey
| | - Zeynel Duman
- Department of Cardiovascular Surgery, Çukurova University School of Medicine, Adana, Turkey
| | | | - M Kemal Avşar
- Department of Cardiovascular Surgery, Medicana International Hospital, İstanbul, Turkey
| | - Atakan Atalay
- Department of Cardiovascular Surgery, Çukurova University School of Medicine, Adana, Turkey
| | - Bahattin Çiftçi
- Department of Cardiovascular Surgery, Çukurova University School of Medicine, Adana, Turkey
| | - İhsan Bayraktar
- Department of Cardiovascular Surgery, Çukurova University School of Medicine, Adana, Turkey
| | - Funda Tor
- Department of Cardiovascular Surgery, Çukurova University School of Medicine, Adana, Turkey
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Abstract
Suboptimal neurodevelopmental outcome is common in children who have congenital heart disease. Its aetiology is often multifactorial. This review focuses on the role of cardiopulmonary bypass. Hypothermia is the mainstay of cerebral protection. Low flow and regional low flow are preferred to deep hypothermic circulatory arrest in many situations. Cooling and rewarming, aortopulmonary collaterals, pH, air emboli, the systemic inflammatory response, haematocrit, oxygenation, glucose and ultrafiltration can influence neurodevelopmental outcome. Although no pharmacological agents have been shown to have a beneficial effect on neurodevelopmental outcome in clinical practice in children, animal work on the use of steroids several hours before surgery is encouraging.
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Chew MS, Brix-Christensen V, Ravn HB, Brandslund I, Ditlevsen E, Pedersen J, Hjortholm K, Hansen OK, Tønnesen E, Hjortdal VE. Effect of modified ultrafiltration on the inflammatory response in paediatric open-heart surgery: a prospective, randomized study. Perfusion 2016; 17:327-33. [PMID: 12243435 DOI: 10.1191/0267659102pf595oa] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Modified ultrafiltration (MUF) is often used in conjunction with paediatric cardiac surgery with cardiopulmonary bypass (CPB) and is thought to improve clinical outcome. It is unclear whether these improvements (if any) are due to the removal of inflammatory mediators. In this prospective study, 18 children aged 12-24 months undergoing uncomplicated cardiac surgery with methylprednisolone added in the pump prime were randomized to receive CPB with ( n= 10) and without ( n= 8) MUF. Cytokines (TNFα, IL-6, IL- 1β, IL-10, IL-1ra), complement split products (C3d, C4d) and coagulation system activation (F1+ 2, ATIII) were measured pre-, peri- and up to 48 h postoperatively. For clinical outcome, the alveolar-arterial oxygen (A-a) gradient, transfusion requirement, drain loss, mean blood pressure and requirement for inotropic support were registered up to 24 h postoperatively. Our results show an improvement in postoperative oxygenation as well as a tendency towards decreased drain loss and improved haemodynamics in the MUF group. There were no intergroup differences detectable for TNFα, IL-1β, IL-1ra, complement and coagulation markers. We conclude that MUF in itself does not significantly influence TNFα, IL-1β, IL-1ra and the complement and coagulation profiles in children undergoing cardiac surgerywith CPB. Despite this, there was some evidence for improved clinical outcome. Our results do not support that MUF improves postoperative organ function by modulation of the measured markers of inflammation.
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Affiliation(s)
- Michelle S Chew
- Department of Anaesthesia and Intensive Care, Institute of Experimental Clinical Research, Aarhus University Hospital, Denmark.
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