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Dourson AJ, Jankowski MP. Developmental impact of peripheral injury on neuroimmune signaling. Brain Behav Immun 2023; 113:156-165. [PMID: 37442302 PMCID: PMC10530254 DOI: 10.1016/j.bbi.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/01/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023] Open
Abstract
A peripheral injury drives neuroimmune interactions at the level of the injury and throughout the neuraxis. Understanding these systems will be beneficial in the pursuit to target persistent pain that involves both neural and immune components. In this review, we discuss the impact of injury on the development of neuroimmune signaling, along with data that suggest a possible cellular immune memory. We also discuss the parallel effects of injury in the nervous system and immune related areas including bone marrow, lymph node and central nervous system-related cells. Finally, we relate these findings to patient populations and current research that evaluates human tissue.
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Affiliation(s)
- Adam J Dourson
- Department of Anesthesia, Division of Pain Management, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States
| | - Michael P Jankowski
- Department of Anesthesia, Division of Pain Management, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, United States; Pediatric Pain Research Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
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van Saet A, Tibboel D. The influence of cardiopulmonary bypass on pediatric pharmacokinetics. Expert Opin Drug Metab Toxicol 2023; 19:333-344. [PMID: 37334571 DOI: 10.1080/17425255.2023.2227556] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 06/16/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Every year thousands of children undergo surgery for congenital heart disease. Cardiac surgery requires the use of cardiopulmonary bypass, which can have unexpected consequences for pharmacokinetic parameters. AREAS COVERED We describe the pathophysiological properties of cardiopulmonary bypass that may influence pharmacokinetic parameters, with a focus on literature published in the last 10 years. We performed a PubMed database search with the keywords 'Cardiopulmonary bypass' AND 'Pediatric' AND 'Pharmacokinetics'. We searched related articles on PubMed and checked the references of articles for relevant studies. EXPERT OPINION Interest in the influence of cardiopulmonary bypass on pharmacokinetics has increased over the last 10 years, especially due to the use of population pharmacokinetic modeling. Unfortunately, study design usually limits the amount of information that can be obtained with sufficient power and the best way to model cardiopulmonary bypass is yet unknown. More information is needed on the pathophysiology of pediatric heart disease and cardiopulmonary bypass. Once adequately validated, PK models should be integrated in the patient electronic database integrating covariates and biomarkers influencing PK, making it possible to predict real-time drug concentrations and guide further clinical management for the individual patient at the bedside.
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Affiliation(s)
- Annewil van Saet
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Intensive Care and Pediatric Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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3
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van Saet A, Zeilmaker-Roest GA, Stolker RJ, Bogers AJJC, Tibboel D. Methylprednisolone in Pediatric Cardiac Surgery: Is There Enough Evidence? Front Cardiovasc Med 2021; 8:730157. [PMID: 34631828 PMCID: PMC8492975 DOI: 10.3389/fcvm.2021.730157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/06/2021] [Indexed: 11/14/2022] Open
Abstract
Corticosteroids have been used to decrease the inflammatory response to cardiac surgery and cardiopulmonary bypass in children for decades. Sparse information is present concerning the pharmacokinetics and pharmacodynamics of corticosteroids in the context of pediatric cardiac surgery. There is large interindividual variability in plasma concentrations, with indications for a larger volume of distribution in neonates compared to other age groups. There is ample evidence that perioperative use of MP leads to a decrease in pro-inflammatory mediators and an increase in anti-inflammatory mediators, with no difference in effect between doses of 2 and 30 mg/kg. No differences in inflammatory mediators have been shown between different times of administration relative to the start of surgery in various studies. MP has been shown to have a beneficial effect in certain subgroups of patients but is also associated with side effects. In lower risk categories, the balance between risk and benefit may be shifted toward risk. There is limited information on short- to medium-term outcome (mortality, low cardiac output syndrome, duration of mechanical ventilation, length of stay in the intensive care unit or the hospital), mostly from underpowered studies. No information on long-term outcome, such as neurodevelopmental outcome, is available. MP may provide a small benefit that is easily abolished by patient characteristics, surgical techniques, and perfusion management. The lack of evidence leads to large differences in practice between and within countries, and even within hospitals, so there is a need for adequately powered randomized studies.
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Affiliation(s)
- Annewil van Saet
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Gerdien A Zeilmaker-Roest
- Department of Intensive Care and Pediatric Surgery, Erasmus Medical Center, Rotterdam, Netherlands.,Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Robert J Stolker
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Intensive Care and Pediatric Surgery, Erasmus Medical Center, Rotterdam, Netherlands
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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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Intraoperative Steroid Use and Outcomes Following the Norwood Procedure: An Analysis of the Pediatric Heart Network's Public Database. Pediatr Crit Care Med 2016; 17:30-5. [PMID: 26492058 PMCID: PMC4703451 DOI: 10.1097/pcc.0000000000000541] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Data supporting the use of perioperative steroids during cardiac surgery are conflicting, and most pediatric studies have been limited by small sample sizes and/or diverse cardiac diagnoses. The objective of this study was to determine if intraoperative steroid administration improved outcomes following the Norwood procedure. DESIGN A retrospective analysis was performed on the 549 neonates who underwent a Norwood procedure in the publicly available datasets from the Pediatric Heart Network's Single Ventricle Reconstruction trial. Groups were compared to determine if outcomes differed between intraoperative steroid recipients (n = 498, 91%) and nonrecipients (n = 51, 9%). SETTING Fifteen North American centers. SUBJECTS Infants enrolled in the Single Ventricle Reconstruction trial. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Baseline characteristics and intraoperative variables were similar between groups with the exception of a shorter duration of cross clamp and cardiopulmonary bypass time in the group that received steroids. Subjects who did not receive intraoperative steroids had improved hospital survival (94% vs 83%, p = 0.03) but longer ICU stays (16 d; interquartile range, 12-33 vs 14 d; interquartile range, 9-28; p = 0.04) and hospital stays (29 d; interquartile range, 21-50 vs 23 d; interquartile range, 15-40; p = 0.01) than steroid recipients. In multivariate analysis, lengths of stay associations were no longer significant, but hospital survival trended toward favoring the nonsteroid group with an odds ratio of 3.52 (95% CI, 0.98-12.64; p = 0.054). CONCLUSIONS In the large multicentered Single Ventricle Reconstruction trial, there was widespread use of intraoperative steroids. Intraoperative steroid administration was not associated with an improvement in outcomes and may be associated with a reduction in hospital survival in neonates undergoing the Norwood procedure. This study highlights the need for a randomized control trial.
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Graham EM, Atz AM, McHugh KE, Butts RJ, Baker NL, Stroud RE, Reeves ST, Bradley SM, McGowan FX, Spinale FG. Preoperative steroid treatment does not improve markers of inflammation after cardiac surgery in neonates: results from a randomized trial. J Thorac Cardiovasc Surg 2013; 147:902-8. [PMID: 23870160 DOI: 10.1016/j.jtcvs.2013.06.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 04/12/2013] [Accepted: 06/14/2013] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Neonatal cardiac surgery requiring cardiopulmonary bypass results in a heightened inflammatory response. Perioperative glucocorticoid administration is commonly used in an attempt to reduce the inflammatory cascade, although characterization of the cytokine response to steroids in neonatal cardiac surgery remains elusive because of highly variable approaches in administration. This randomized trial was designed to prospectively evaluate the effect of specific glucocorticoid dosing protocols on inflammatory markers in neonatal cardiac surgery requiring cardiopulmonary bypass. METHODS Neonates scheduled for cardiac surgery were randomly assigned to receive either 2-dose (8 hours preoperatively and operatively, n = 36) or single-dose (operatively, n = 32) methylprednisolone at 30 mg/kg per dose in a prospective double-blind trial. The primary outcome was the effect of these steroid regimens on markers of inflammation. Secondary analyses evaluated the association of specific cytokine profiles with postoperative clinical outcomes. RESULTS Patient demographics, perioperative variables, and preoperative indices of inflammation were similar between the single- and 2-dose groups. Preoperative cytokine response after the 2-dose methylprednisolone protocol was consistent with an anti-inflammatory effect, although this did not persist into the postoperative period. Premedication baseline levels of interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor α were predictive of postoperative intensive care unit and hospital length of stay. Only interleukin-8 demonstrated a postoperative response associated with duration of intensive care unit and hospital stay. CONCLUSIONS The addition of a preoperative dose of methylprednisolone to a standard intraoperative methylprednisolone dose does not improve markers of inflammation after neonatal cardiac surgery. The routine administration of preoperative glucocorticoids in neonatal cardiac surgery should be reconsidered.
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Affiliation(s)
- Eric M Graham
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC.
| | - Andrew M Atz
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Kimberly E McHugh
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Ryan J Butts
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Nathaniel L Baker
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Robert E Stroud
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Scott T Reeves
- Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC
| | - Scott M Bradley
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Francis X McGowan
- Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC
| | - Francis G Spinale
- Departments of Surgery and Cell Biology and Anatomy, USC School of Medicine, Columbia, SC
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Schwartz SM, Anand KJS, Portman MA, Crow S, Nelson DP, Zimmerman JJ. Endocrinopathies in the cardiac ICU. World J Pediatr Congenit Heart Surg 2013; 2:400-10. [PMID: 23803992 DOI: 10.1177/2150135111406941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The past several years have seen an increased appreciation of the potential role of the endocrine system in the recovery process following surgery for congenital heart disease. Many of the hormonal changes following cardiac surgery are adaptive and necessary, whereas activation of proinflammatory cytokine and chemokine responses and some of the metabolic changes following surgery are likely mediators leading to detrimental outcomes. Additionally, other hormonal perturbations may contribute to adverse outcomes. This review examines the pain and the stress response, thyroid function and hyperglycemia following cardiopulmonary bypass (CPB), and the potential role of corticosteroids in the pediatric cardiac critical care unit.
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Affiliation(s)
- Steven M Schwartz
- Department of Critical Care Medicine and The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
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Garisto C, Favia I, Ricci Z, Chiara LD, Morelli S, Giorni C, Vitale V, Picardo S, Di Donato RM. Initial Single-Center Experience With Levosimendan Infusion for Perioperative Management of Univentricular Heart With Ductal-Dependent Systemic Circulation. World J Pediatr Congenit Heart Surg 2010; 1:292-9. [DOI: 10.1177/2150135110378310] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to evaluate the safety and the efficacy of levosimendan, a novel calcium sensitizer agent, on postoperative hemodynamic and metabolic parameters of neonates affected by single ventricle anatomy. Twenty consecutive neonates scheduled for the Norwood procedure with Blalock Taussig shunt were prospectively enrolled. All patients received an infusion of levosimendan at 0.1 μg/kg/min commencing 24 hours before surgery, and the infusion was continued for 48 hours after surgery. No side effects (intolerance to the drug, hypotension, arrhythmias) were shown. A median inotropic score (IS) of 37 was necessary to maintain a mean arterial pressure between 45 and 50 mm Hg at intensive care unit (ICU) admission: IS was significantly reduced after 72 hours ( P < .05). Brain natriuretic peptide values decreased significantly from 1210 to 459 pg/mL in 72 hours ( P < .05). Median SvO2 increased significantly from 38% to 59% during the evaluated period ( P < .05). Cerebral near-infrared spectroscopy values were close to 40% at ICU admission with a significant stable increase to 50% after 12 hours ( P < .05). Median lactate level was 13 mmol/L at ICU admission but showed a trend to a rapid and significant decrease after 12 hours ( P < .05). Median urine output was surprisingly elevated, always remaining between 5.2 and 6.2 mL/kg/h throughout the postoperative period. Survival rate was 85% at 30 days (17/20 patients) and 75% (15/20) at hospital discharge. Levosimendan infusion in a cohort of neonates with univentricular anatomy was safe and potentially beneficial on postoperative hemodynamic and metabolic parameters.
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Affiliation(s)
- Cristiana Garisto
- Division of Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Pediatric Hospital, Rome, Italy
| | - Isabella Favia
- Division of Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Pediatric Hospital, Rome, Italy
| | - Zaccaria Ricci
- Division of Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Pediatric Hospital, Rome, Italy
| | - Luca Di Chiara
- Division of Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Pediatric Hospital, Rome, Italy
| | - Stefano Morelli
- Division of Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Pediatric Hospital, Rome, Italy
| | - Chiara Giorni
- Division of Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Pediatric Hospital, Rome, Italy
| | - Vincenzo Vitale
- Division of Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Pediatric Hospital, Rome, Italy
| | - Sergio Picardo
- Division of Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Pediatric Hospital, Rome, Italy
| | - Roberto M. Di Donato
- Division of Pediatric Cardiac Surgery, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Pediatric Hospital, Rome, Italy
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Caputo M, Bays S, Rogers CA, Pawade A, Parry AJ, Suleiman S, Angelini GD. Randomized Comparison Between Normothermic and Hypothermic Cardiopulmonary Bypass in Pediatric Open-Heart Surgery. Ann Thorac Surg 2005; 80:982-8. [PMID: 16122470 DOI: 10.1016/j.athoracsur.2005.03.062] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2004] [Revised: 03/08/2005] [Accepted: 03/16/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study is to investigate the effect of cardiopulmonary bypass (CPB) temperature on myocardial reperfusion injury, oxidative stress, and inflammatory response in pediatric open heart surgery. METHODS Fifty-nine children (median age 78 months; interquartile range, 39-130) undergoing correction of simple congenital heart defects were randomized to receive either hypothermic (28 degrees C) or normothermic (35-37 degrees C) CPB. Troponin I and 8-isoprostane, complement activation C3a, interleukin (IL) -6, -8, and -10, were measured preoperatively, on removal of the aortic cross clamp, 30 minutes, 6, and 24 hours postoperatively. RESULTS Troponin I and 8-isoprostane were significantly raised, compared to baseline, in both groups, and remained high at 24 hours. Overall, troponin I and 8-isoprostane levels were 37% and 84% higher in the hypothermic than in the normothermic group, respectively (ratio 1.37, 95% CI 1.00 to 1.88, p = 0.053 and 1.84, 95% CI 1.22 to 2.78, p = 0.0045, respectively), and there was no evidence to suggest the treatment effect changed significantly over the time points measured (p = 0.63). Adjusting for aortic cross-clamp time reduced the effect of hypothermia on troponin (p = 0.18) but not on 8-isoprostane levels (p = 0.0028). The C3a, IL-6, and IL-8 release was similar in the two groups. The IL-10 release between the groups changed over time (p = 0.059) and examining differences at individual time points highlighted a statistically significant difference at the end of the cross-clamp time (p = 0.0079). CONCLUSIONS Normothermic CPB is associated with reduced oxidative stress compared with hypothermic CPB, and similar myocardial reperfusion injury and whole body inflammatory response, in children undergoing open heart surgery. A larger study with clinical outcomes as primary end points is now warranted.
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Affiliation(s)
- Massimo Caputo
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom
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Schumacher K, Korr S, Vazquez-Jimenez JF, von Bernuth G, Duchateau J, Seghaye MC. Does cardiac surgery in newborn infants compromise blood cell reactivity to endotoxin? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:R549-55. [PMID: 16277717 PMCID: PMC1297621 DOI: 10.1186/cc3794] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2005] [Revised: 07/13/2005] [Accepted: 07/15/2005] [Indexed: 11/24/2022]
Abstract
Introduction Neonatal cardiac surgery is associated with a systemic inflammatory reaction that might compromise the reactivity of blood cells against an inflammatory stimulus. Our prospective study was aimed at testing this hypothesis. Methods We investigated 17 newborn infants with transposition of the great arteries undergoing arterial switch operation. Ex vivo production of the pro-inflammatory cytokine tumor necrosis factor-α (TNF-α), of the regulator of the acute-phase response IL-6, and of the natural anti-inflammatory cytokine IL-10 were measured by enzyme-linked immunosorbent assay in the cell culture supernatant after whole blood stimulation by the endotoxin lipopolysaccharide before, 5 and 10 days after the operation. Results were analyzed with respect to postoperative morbidity. Results The ex vivo production of TNF-α and IL-6 was significantly decreased (P < 0.001 and P < 0.002, respectively), whereas ex vivo production of IL-10 tended to be lower 5 days after the operation in comparison with preoperative values (P < 0.1). Ex vivo production of all cytokines reached preoperative values 10 days after cardiac surgery. Preoperative ex vivo production of IL-6 was inversely correlated with the postoperative oxygenation index 4 hours and 24 hours after the operation (P < 0.02). In contrast, postoperative ex vivo production of cytokines did not correlate with postoperative morbidity. Conclusion Our results show that cardiac surgery in newborn infants is associated with a transient but significant decrease in the ex vivo production of the pro-inflammatory cytokines TNF-α and IL-6 together with a less pronounced decrease in IL-10 production. This might indicate a transient postoperative anti-inflammatory shift of the cytokine balance in this age group. Our results suggest that higher preoperative ex vivo production of IL-6 is associated with a higher risk for postoperative pulmonary dysfunction.
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Affiliation(s)
- Kathrin Schumacher
- Fellow in pediatrics, Department of Pediatric Cardiology, Aachen University, Aachen, Germany
| | - Stefanie Korr
- Fellow in internal medicine, Department of Pediatric Cardiology, Aachen University, Aachen, Germany
| | - Jaime F Vazquez-Jimenez
- Head of department, Department of Pediatric Cardiac Surgery, Aachen University, Aachen, Germany
| | - Götz von Bernuth
- Former head of department, Department of Pediatric Cardiology, Aachen University, Aachen, Germany
| | - Jean Duchateau
- Director, Department of Immunology, University Hospital Brugmann and Saint-Pierre, Free University of Brussels, Brussels, Belgium
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Yadavalli GK, Chien JW, Wener KM, Devecchio JL, Gupta S, Salata RA, Lee JH, Caldeira C, Auletta JJ, Heinzel FP. INTERLEUKIN 12 AND INTERFERON-?? SYNTHETIC DEFICIENCY IS ASSOCIATED WITH DENDRITIC CELL CYTOPENIA AFTER CARDIAC SURGERY. Shock 2005; 24:26-33. [PMID: 15988317 DOI: 10.1097/01.shk.0000167110.73129.a8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Traumatic or inflammatory injury associates with deactivation of monocytes and impaired synthesis of proinflammatory cytokines. We conducted a prospective, observational study to test whether cardiac surgery additionally impaired dendritic and natural killer (NK) cell functions responsible for innate immune production of interleukin (IL)-12-dependent interferon (IFN)-gamma in response to bacteria or toll-like receptor agonists. Blood samples were taken just before induction of anesthesia and 24 h postoperatively. LPS- and fixed Staphylococcus aureus-inducible IFNgamma synthesis in whole blood culture after surgery was reduced to 5% of preoperative values (P < 0.001). Production of IL-12 p70, a critical inducer of IFNgamma in the innate immune response, was reduced to 30% of that produced by preoperative samples (P = 0.013). Circulating CD11c, DR myeloid dendritic cells (DC) that are known sources of IL-12 p70 in normal blood, declined to approximately 25% of presurgical numbers (P = 0.004). Experimental depletion of CD11c, but not CD14, cells from normal peripheral blood mononuclear cell (PBMC) similarly disabled Staphylococcus aureus Cowan 1 (SAC)-induced production of IL-12 p70 and IFNgamma. Consistent with SAC-induced IFNgamma expression in CD56 NK and NK-T cells, CD56 depletion ablated IFNgamma production in normal whole blood. However, repletion of IL-12 p70, IL-18, IL-15, and IL-23 in postoperative blood failed to restore presurgical levels of IFNgamma synthesis (P < 0.05). We conclude that DC cytopenia after major surgery is sufficient to explain postoperative IL-12 p70 and IFNgamma synthetic deficiency. In addition, postoperative blood became hyporesponsive to IFNgamma-inducing cytokines as a further contribution to IFNgamma insufficiency. The novel finding of DC cytopenia after major surgery may portend a lack of other immunologic functions provided by this potent accessory cell population.
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Affiliation(s)
- Gopala K Yadavalli
- Division of Infectious Diseases, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA.
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12
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Alcaraz AJ, Manzano L, Sancho L, Vigil MD, Esquivel F, Maroto E, Reyes E, Alvarez-Mon M. Different Proinflammatory Cytokine Serum Pattern in Neonate Patients Undergoing Open Heart Surgery. Relevance of IL-8. J Clin Immunol 2005; 25:238-45. [PMID: 15981089 DOI: 10.1007/s10875-005-4081-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Accepted: 12/29/2004] [Indexed: 11/30/2022]
Abstract
The purpose of this work was to investigate the clinical significance of serum levels of proinflammatory cytokines in pediatric patients undergoing cardiopulmonary bypass. We divided the patients in two groups: 8 neonates, and 19 non-newborn children. IL-1beta, IL-6, IL-8, and TNF serum levels were quantified before sternotomy, at admission to the PICU (30 min postoperatively), 24 h after the onset of surgery and 3 days after the operation. Surgical cardiac stress elicits significant increments of IL-6, IL-8 and TNF serum concentrations in both neonates and non-neonates, regardless of their preoperative clinical condition. However, in newborns the magnitude of the proinflammatory cytokine increments was, in particular with IL-8, remarkably greater than in older children. Moreover, neonate and non-neonate patients showed clearly disparate patterns of serum concentrations over time of both IL-8 and TNF. There was a marked relationship between IL-8 levels and postoperative morbidity, evaluated by pulmonary dysfunction, days on inotropic support and days of PICU stay in both neonates and non-neonates patients. In contrast, we found no relationship between serum levels of IL-6 and TNF and postoperative clinical data. Newborn and non-newborn patients undergoing cardiopulmonary bypass exhibit dissimilar patterns of proinflammatory cytokines. IL-8 might be implicated in the multiorganic dysfunction related to cardiopulmonary bypass in pediatric patients.
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Affiliation(s)
- A J Alcaraz
- Departamento de Pediatría y Cirugía Pediátrica, Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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13
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Hasegawa T, Yamaguchi M, Yoshimura N, Okita Y. The dependence of myocardial damage on age and ischemic time in pediatric cardiac surgery. J Thorac Cardiovasc Surg 2005; 129:192-8. [PMID: 15632842 DOI: 10.1016/j.jtcvs.2004.05.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Heart fatty acid-binding protein is a rapid indicator for assessment of myocardial damage in cardiac surgery. The purpose of this study was to investigate the effects of age and ischemic time on the biochemical evidence and clinical outcomes of myocardial damage in pediatric cardiac surgery. METHODS A prospective observational cohort study conducted over 2.5 years was performed in 98 consecutive patients (51 infants and 47 children) undergoing cardiac surgery for ventricular septal defects. Serial measurements of serum levels of heart fatty acid-binding protein and the respective areas under the curve were obtained, with particular reference to age and aortic crossclamp time. Assessment of clinical outcomes included inotropic support, ventilatory support, and intensive care unit stay. RESULTS There was a linear dependence of the logarithm of age and the logarithm of heart fatty acid-binding protein release(r = 0.737, P < .0001). This logarithm-logarithm plot showed a power function of age for heart fatty acid-binding protein release. The exponent and amplitude parameter of the power function was the aortic crossclamp time. Compared with children, infants had significantly more myocardial damage and worse clinical outcomes, and these factors were related to the aortic crossclamp time. CONCLUSIONS The younger the age of patients, the more vulnerable are their myocardia to injury caused by ischemia during definitive repair of congenital heart disease. Therefore, perioperative management for pediatric patients after cardiac surgery should be performed, taking into consideration the dependence of the myocardial damage on age and ischemic time.
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Affiliation(s)
- Tomomi Hasegawa
- Division of Cardiovascular Thoracic, and Pediatric Surgery, Department of Cardio-pulmonary and Vascular Medicine, Kobe University Graduate School of Medicine, Japan
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Chang AC. Inflammatory mediators in children undergoing cardiopulmonary bypass: is there a unified field theory amidst this biomolecular chaos? Pediatr Crit Care Med 2003; 4:386-7. [PMID: 12840606 DOI: 10.1097/01.pcc.0000074265.61315.86] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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15
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Haddad JJ, Fahlman CS. Redox- and oxidant-mediated regulation of interleukin-10: an anti-inflammatory, antioxidant cytokine? Biochem Biophys Res Commun 2002; 297:163-76. [PMID: 12237098 DOI: 10.1016/s0006-291x(02)02094-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Reduction-oxidation (redox) state constitutes such a potential signaling mechanism for the regulation of an inflammatory signal associated with oxidative stress. Interleukin (IL)-10 has recently emerged as an anti-inflammatory cytokine with antioxidant properties. Interestingly, redox- and oxidant-mediated pathways positively and/or negatively regulate the expression, distribution, and functional properties of IL-10, thus, allowing the evolution of what is known as an anti-inflammatory redox-oxidant revolving axis. This axis is directly involved in regulating phosphorylation mechanisms, which eventually control gene expression and the biosynthesis of oxidative stress-related cofactors, such as reactive species and inflammatory cytokines. The association between IL-10, an anti-inflammatory antioxidant, with redox- and oxidant-related pathways governing the regulation of inflammatory and closely dependent processes is thereafter discussed.
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Affiliation(s)
- John J Haddad
- Severinghaus-Radiometer Research Laboratories, Molecular Neuroscience Research Division, Department of Anesthesia and Perioperative Care, University of California at San Francisco, School of Medicine, 94143-0542, USA.
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