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Ontaneda AM, Coss-Bu JA, Kennedy C, Akcan-Arikan A, Fernandez E, Lasa JJ, Price JF, Shekerdemian LS. Post-operative dysnatremia is associated with adverse early outcomes after surgery for congenital heart disease. Pediatr Res 2023:10.1038/s41390-023-02495-4. [PMID: 36707662 DOI: 10.1038/s41390-023-02495-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 12/17/2022] [Accepted: 01/15/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND Dysnatremia is a common disorder in critically ill surgical children. The study's aim is to determine the prevalence of dysnatremia and its association with outcomes after surgery for congenital heart disease (CHD). METHODS This is a single-center retrospective cohort study of children <18 years of age undergoing surgery for CHD between January 2012 and December 2014. Multivariable logistic regression analysis was used to evaluate the relationship between dysnatremia and outcomes during the perioperative period. A total of 1345 encounters met the inclusion criteria. RESULTS The prevalence of pre- and post-operative dysnatremia were 10.2% and 47.1%, respectively. Hyponatremia occurred in 19.1%, hypernatremia in 25.6%. Hypernatremia at 24, 48, and 72 h post-operative was associated with increased hospital mortality (odds ratios (OR) [95% confidence intervals (CI)] 3.08 [1.16-8.17], p = 0.024; 4.35 [1.58-12], p = 0.0045; 4.14 [1.32-12.97], p = 0.0148, respectively. Hypernatremia was associated with adverse neurological events 3.39 [1.12-10.23], p = 0.0302 at 48 h post-operative. Hyponatremia was not associated with any adverse outcome in our secondary analysis. CONCLUSIONS Post-operative dysnatremia is a common finding in this heterogeneous cohort of pediatric cardiac-surgical patients. Hypernatremia was more prevalent than hyponatremia and was associated with adverse early post-operative outcomes. IMPACT Our study has shown that dysnatremia was highly prevalent in children after congenital heart surgery with hypernatremia associated with adverse outcomes including mortality. It is important to understand fluid and sodium regulation in the post-operative period in children with congenital heart disease to better address fluid overload and associated electrolyte imbalances and acute kidney injury. While clinicians are generally very aware of the importance of hyponatremia in critically ill children, similar attention should be given to hypernatremia in this population.
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Affiliation(s)
- Andrea M Ontaneda
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
| | - Jorge A Coss-Bu
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Curtis Kennedy
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Ayse Akcan-Arikan
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.,Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Ernesto Fernandez
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Javier J Lasa
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Jack F Price
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Lara S Shekerdemian
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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2
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Busse LW, Barker N, Petersen C. Vasoplegic syndrome following cardiothoracic surgery-review of pathophysiology and update of treatment options. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:36. [PMID: 32019600 PMCID: PMC7001322 DOI: 10.1186/s13054-020-2743-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
Abstract
Vasoplegic syndrome is a common occurrence following cardiothoracic surgery and is characterized as a high-output shock state with poor systemic vascular resistance. The pathophysiology is complex and includes dysregulation of vasodilatory and vasoconstrictive properties of smooth vascular muscle cells. Specific bypass machine and patient factors play key roles in occurrence. Research into treatment of this syndrome is limited and extrapolated primarily from that pertaining to septic shock, but is evolving with the expanded use of catecholamine-sparing agents. Recent reports demonstrate potential benefit in novel treatment options, but large clinical trials are needed to confirm.
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Affiliation(s)
- Laurence W Busse
- Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA. .,Emory Johns Creek Hospital, 6325 Hospital Parkway, Johns Creek, GA, 30097, USA.
| | - Nicholas Barker
- Department of Pharmacy, Emory St. Joseph's Hospital, Atlanta, GA, USA
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3
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Brancaccio G, Michielon G, Di Donato RM, Costa D, Falzea F, Miraldi F. Atrial natriuretic factor in normothermic and hypothermic cardiopulmonary bypass. Perfusion 2016; 19:157-62. [PMID: 15298423 DOI: 10.1191/0267659104pf732oa] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: To evaluate the plasmatic changes of atrial natriuretic factor (ANF) during and after cardiopulmonary bypass (CPB) in normothermia and hypothermia. Methods: Twenty-three patients (n=23) undergoing coronary artery bypass graft surgery were randomly assigned to two groups. In Group I (n=11), the patients underwent operation in normothermia; in Group II (n=12), the operation was performed in hypothermia (268C). Results: Plasma ANF levels were determined after induction of anaesthesia, at the end of CPB and one hour postoperatively. There were no demographic differences between the two groups, diuresis (p=0.90) and natriuresis (p=0.95). Plasma levels of ANF were significantly elevated during and after CPB in both groups (p <0.01). The groups differed significantly for plasma levels of ANF during CPB and postoperatively ( p<0.05), but did not differ prebypass (p=0.08). There was no correlation in either group between ANF release and central venous pressure, natriuresis and diuresis. There was only a borderline relationship between ANF concentration and diuresis after CPB in Group I. Conclusion: CPB triggers the production and release of ANF. The present study demonstrates a significantly enhanced ANF release during hypothermia and reperfusion after ischaemia. Thus, these data suggest the protective role of ANF on the hypoxic myocardium, and they confirm that ANF does not play a role in diuresis and natriuresis during and after hypothermic CPB.
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Affiliation(s)
- Gianluca Brancaccio
- Department of Pediatric Cardiac Surgery, Bambino Gesù Hospital, Rome, Italy.
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Baer J, Stoops S, Flynn B. Vasodilatory Shock After Ventricular Assist Device Placement: A Bench to Bedside Review. Semin Thorac Cardiovasc Surg 2016; 28:238-244. [PMID: 28043423 DOI: 10.1053/j.semtcvs.2016.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2016] [Indexed: 11/11/2022]
Abstract
With more than 2000 ventricular assist devices (VAD) placed annually in the United States, understanding postoperative management is important. One of the most common postoperative morbidities encountered with VAD implantation is vasodilatory shock. The mechanisms for this phenomenon are numerous and include cellular and hormonal aberrancies unique to the VAD recipient. Management of vasodilatory shock in VAD patients needs to be undertaken with an understanding of the side effects associated with each treatment, especially the effects on the right ventricle and pulmonary vasculature. This article focuses on the incidence, the pathogenesis, the consequences, and the management of vasodilatory shock in the postoperative VAD patient.
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Affiliation(s)
- John Baer
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Shea Stoops
- Department of Anesthesiology and Critical Care, University of Kansas Medical Center, Kansas City, Kansas
| | - Brigid Flynn
- Department of Anesthesiology and Critical Care, University of Kansas Medical Center, Kansas City, Kansas
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5
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Lee JJ, Kim YS, Jung HH. Acute serum sodium concentration changes in pediatric patients undergoing cardiopulmonary bypass and the association with postoperative outcomes. SPRINGERPLUS 2015; 4:641. [PMID: 26543775 PMCID: PMC4628041 DOI: 10.1186/s40064-015-1436-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/14/2015] [Indexed: 12/01/2022]
Abstract
The objective of this study is to investigate the degree of serum sodium changes and its association with patient outcomes in pediatrics undergoing heart surgery with cardiopulmonary bypass (CPB). We reviewed the medical records of 275 pediatric patients who underwent heart surgery with CPB. Prior to CPB, hyponatremia (≤135 mmol/L) was observed in 21 of 275 patients. After initiation of CPB, serum sodium decreased significantly and severe hyponatermia (≤130 mmol/L) subsequently developed in 32 patients. At the end of CPB, however, hypernatremia (≥145 mmol/L) developed in 86 patients. The degree of acute serum sodium change during CPB was not associated with patient outcomes. However, the patients with preoperative hyponatremia and those with hypernatremia at the conclusion of CPB had longer hospital stays and higher postoperative complication rates. Lower serum sodium prior to CPB and higher serum sodium at the end of CPB, along with age and duration of the operation, were independently associated with worse in-hospital outcomes. Acute and transient hyponatremia occurred frequently after initiation of CPB, and then serum sodium immediately increased above preoperative levels at the end of CPB. Caution is required to avoid serum sodium overcorrection on the conclusion of CPB.
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Affiliation(s)
- Jeong Jin Lee
- Department of Anaesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young-Soon Kim
- Department of Anaesthesiology and Pain Medicine, Seoul Woman's Hospital, Gyeonggi-do, Bucheon, South Korea
| | - Hae Hyuk Jung
- Department of Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, 156 Baekryung-ro Gangwon-do, Chuncheon, 200-722 South Korea
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Affiliation(s)
- Michael G Fitzsimons
- Department of Anesthesia and Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA.
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7
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Terazawa E, Dohi S, Akamastsu S, Ohata H, Shimonaka H. Changes in calcitonin gene-related peptide, atrial natriuretic peptide and brain natriuretic peptide in patients undergoing coronary artery bypass grafting. Anaesthesia 2003; 58:223-32. [PMID: 12603452 DOI: 10.1046/j.1365-2044.2003.03037.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The initiation of cardiopulmonary bypass creates significant derangements in cardiovascular volume status and both endocrine and autonomic nervous system function. To examine whether such derangements might differ in patients with different pre-operative physical status scores, we measured the plasma concentrations of calcitonin gene-related peptide, atrial natriuretic peptide and brain natriuretic peptide, catecholamines and antidiuretic hormone, as well as haemodynamic variables, during and after cardiopulmonary bypass in 27 consecutive patients undergoing coronary artery bypass grafting. The pre-operative levels of atrial natriuretic peptide and brain natriuretic peptide differed significantly between ASA II patients and III and IV patients [mean (SD) brain natriuretic peptide levels = 14 (8.2) vs. 129 (51) pg.ml-1]. Plasma calcitonin gene-related peptide increased significantly in both groups after the initiation of cardiopulmonary bypass, and remained increased throughout cardiopulmonary bypass. The changes in plasma epinephrine, norepinephrine and antidiuretic hormone were similar to those reported previously. The changes in plasma calcitonin gene-related peptide, atrial natriuretic peptide and brain natriuretic peptide did not correlate with any changes in haemodynamic variables before or after cardiopulmonary bypass. Measurement of plasma brain natriuretic peptide might usefully be included in the pre-operative evaluation of patients with cardiac disease.
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Affiliation(s)
- E Terazawa
- Department of Anaesthesiology and Critical Care Medicine, Gifu University School of Medicine, Tsukasamachi-40, Gifu City, Gifu 500-8705, Japan
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Abstract
A 67-year-old man on long-term carbamazepine therapy underwent elective coronary artery bypass grafting. Following an initially uncomplicated recovery, he developed symptomatic hyponatremia. The symptoms and biochemical abnormality improved after gradual discontinuation of carbamazepine. We discuss the association between carbamazepine and hyponatremia and the causes of hyponatremia after cardiopulmonary bypass. Surgeons should consider stopping carbamazepine before operations with cardiopulmonary bypass.
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Affiliation(s)
- Theodore Velissaris
- Wessex Cardiothoracic Centre, Southampton General Hospital, Southampton, United Kingdom.
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9
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Booth JV, Schinderle D, Welsby IJ. Pro: Vasopressin is the vasoconstrictor of choice after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2002; 16:773-5. [PMID: 12486663 DOI: 10.1053/jcan.2002.128432] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- John V Booth
- Division of Cardiothoracic Anesthesia and Critical Care, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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10
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Albåge A, van der Linden J, Bengtsson L, Lindblom D, Kennebäck G, Berglund H. Elevations in antidiuretic hormone and aldosterone as possible causes of fluid retention in the Maze procedure. Ann Thorac Surg 2001; 72:58-64. [PMID: 11465231 DOI: 10.1016/s0003-4975(01)02688-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Reduced levels of atrial natriuretic peptide (ANP) has been suggested as a cause of fluid retention after combined Maze and valvular surgery. This study aimed to assess hormonal activation in the perioperative setting of isolated Maze procedures. METHODS Changes in ANP, brain natriuretic peptide (BNP), antidiuretic hormone (ADH), aldosterone, and angiotensin II were measured in 16 patients (mean age 53+/-9 years) without concomitant heart disease undergoing the Maze (III) procedure. Ten matched patients (mean age 56+/-9 years) undergoing multivessel coronary artery bypass grafting served as controls. Measurements with hemodynamic correlates were obtained at baseline and after ventricular pacing (100 stimulations/minute), directly preoperatively, postoperatively and the first postoperative day. Weight gain and diuretic requirements were recorded. RESULTS The major differences in hormonal response were significantly higher plasma levels of ADH (Maze preoperative 1.1+/-0.4, postoperative 24.9+/-16.7 pmol/L; controls preoperative 1.1+/-0.1, postoperative 3.7+/-3.5 pmol/L) and aldosterone (Maze preoperative 106+/-94, postoperative 678+/-343 pmol/L; controls preoperative 124+/-79, postoperative 171+/-93 pmol/L) in the Maze group on the first postoperative day (p < 0.001). Preoperative baseline plasma levels of ANP and pulmonary capillary wedge pressures (PCWP) were higher in the Maze group but this difference was abolished by pacing, and postoperatively, ANP levels changed in parallel to the PCWP in both groups. Diuretic requirements were significantly higher in the Maze group. CONCLUSIONS Substantial increases in ADH and aldosterone were observed after the Maze procedure, indicating these hormones as important determinants in postoperative fluid retention. The role for ANP in this setting may be a less prominent than previously reported.
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Affiliation(s)
- A Albåge
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet at Huddinge University Hospital, Stockholm, Sweden.
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Heringlake M, Wagner K, Schumacher J, Pagel H. Urinary excretion of urodilatin is increased during pressure natriuresis in the isolated perfused rat kidney. THE AMERICAN JOURNAL OF PHYSIOLOGY 1999; 277:F347-51. [PMID: 10484517 DOI: 10.1152/ajprenal.1999.277.3.f347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The findings about mechanisms regulating production and excretion of urodilatin [ANP-(95-126)], a member of the atrial natriuretic peptide (ANP) family, are controversial. To elucidate a possible relationship between arterial blood pressure and renal urodilatin excretion, we studied the effects of different perfusion pressures on urine flow (UV), urinary sodium (U(Na)V), urinary potassium (U(K)V), and urodilatin excretion (U(URO)V), and the concentration of urodilatin in the perfusate (P(URO)) of isolated perfused rat kidneys. Kidneys were perfused for 180 min with constant perfusion pressures (80 and 120 mmHg, respectively; each, n = 4) in a closed circuit system. Samples of urine and perfusate were taken every 30 min. Mean UV, U(Na)V, U(K)V, and U(URO)V values were significantly higher with a perfusion pressure of 120 mmHg than with 80 mmHg, whereas P(URO) did not change significantly. Serial measurements revealed no direct relation of U(URO)V with either U(Na)V or UV. This suggests that renal perfusion pressure is a determinant of U(URO)V and that urinary and venous effluent concentrations of urodilatin (probably production) are not coupled directly and that U(URO)V and U(Na)V may dissociate during acute variations of sodium excretion and UV.
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Affiliation(s)
- M Heringlake
- Medizinische Universität zu Lübeck, Klinik für Anaesthesiologie und, D23538 Lübeck, Germany.
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Argenziano M, Chen JM, Choudhri AF, Cullinane S, Garfein E, Weinberg AD, Smith CR, Rose EA, Landry DW, Oz MC. Management of vasodilatory shock after cardiac surgery: identification of predisposing factors and use of a novel pressor agent. J Thorac Cardiovasc Surg 1998; 116:973-80. [PMID: 9832689 DOI: 10.1016/s0022-5223(98)70049-2] [Citation(s) in RCA: 234] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cardiopulmonary bypass can be associated with vasodilatory hypotension requiring pressor support. We have previously found arginine vasopressin to be a remarkably effective pressor in a variety of vasodilatory shock states. We investigated the incidence and clinical predictors of vasodilatory shock in a general population of cardiac surgical patients and the effects of low-dose arginine vasopressin as treatment of this syndrome in patients with heart failure. METHODS Patients undergoing cardiopulmonary bypass (n = 145) were studied prospectively. Preoperative ejection fraction, medications, and perioperative hemodynamics were recorded, and postbypass serum arginine vasopressin levels were measured. Vasodilatory shock was defined as a mean arterial pressure lower than 70 mm Hg, a cardiac index greater than 2.5 L/min/m2, and norepinephrine dependence. Predictors of vasodilatory shock were investigated by logistic regression analysis. The hemodynamic responses of patients who received arginine vasopressin infusions for vasodilatory shock after cardiopulmonary bypass for left ventricular assist device placement or heart transplantation were analyzed retrospectively. RESULTS Eleven of 145 general cardiac surgery patients (8%) met criteria for postbypass vasodilatory shock. By multivariate analysis, an ejection fraction lower than 0.35 and angiotensin-converting enzyme inhibitor use were independent predictors of postbypass vasodilatory shock (relative risks of 9.1 and 11.9, respectively). Vasodilatory shock was associated with inappropriately low serum arginine vasopressin concentrations (12.0 +/- 6.6 pg/mL). Retrospective analysis found 40 patients with postbypass vasodilatory shock who received low-dose arginine vasopressin infusions, resulting in increased mean arterial pressure and decreased norepinephrine requirements. CONCLUSIONS Low ejection fraction and angiotensin-converting enzyme inhibitor use are risk factors for postbypass vasodilatory shock, and this syndrome is associated with vasopressin deficiency. In patients exhibiting this syndrome after high-risk cardiac operations, replacement of arginine vasopressin increases blood pressure and reduces catecholamine pressor requirements.
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Affiliation(s)
- M Argenziano
- Departments of Surgery and Medicine, Columbia University College of Physicians and Surgeons, New York, USA
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