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Ahmed A, Kesman R, Lee ME. Critical Illness-Related Corticosteroid Insufficiency (CIRCI) After Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2024; 15:209-214. [PMID: 38321748 DOI: 10.1177/21501351231221455] [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] [Indexed: 02/08/2024]
Abstract
Although current studies do not support the routine use of corticosteroids after cardiopulmonary bypass in pediatric patients, there is incomplete understanding of the potential hemodynamic contribution of postoperative critical illness-related corticosteroid insufficiency in the intensive care unit. By reviewing the available studies and underlying pathophysiology of these phenomena in critically ill neonates, we can identify a subset of patients that may benefit from optimal diagnosis and treatment of receiving postoperative steroids. A suggested algorithm used at our institution is provided as a guideline for treatment of this high-risk population.
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Affiliation(s)
- Aziez Ahmed
- Section of Critical Care Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Russell Kesman
- Section of Neonatology, Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Madonna E Lee
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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2
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Beckman EJ, Hovey S, Bondi DS, Patel G, Parrish RH. Pediatric Perioperative Clinical Pharmacy Practice: Clinical Considerations and Management: An Opinion of the Pediatrics and Perioperative Care Practice and Research Networks of the American College of Clinical Pharmacy. J Pediatr Pharmacol Ther 2022; 27:490-505. [DOI: 10.5863/1551-6776-27.6.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/24/2021] [Indexed: 11/11/2022]
Abstract
Pediatric perioperative clinical pharmacists are uniquely positioned to provide therapeutic and medication management expertise at a particularly vulnerable transition of care from the preoperative space, through surgery, and postoperative setting. There are many direct-patient care activities that are included in the role of the pediatric perioperative pharmacist, as well as many opportunities to develop effective, optimized, and safe medication use processes. This article outlines many of the areas in which a pediatric perioperative clinical pharmacist may intervene.
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Affiliation(s)
- Elizabeth J. Beckman
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY (EJB)
| | - Sara Hovey
- Department of Pharmacy Practice, University of Illinois at Chicago, College of Pharmacy, University of Illinois Hospital, Chicago, IL (SH)
| | - Deborah S. Bondi
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, IL (DSB, GP)
| | - Gourang Patel
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, IL (DSB, GP)
| | - Richard H. Parrish
- Department of Biomedical Sciences, Mercer University School of Medicine, Columbus, GA (RHP)
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El Derh MS, Abdelaziz NM, Abdel Twab SM. High Dose Methylprednisolone versus Low Dose in Correction of Congenital Acyanotic Heart Disease. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2065817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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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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5
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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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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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7
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Iyer P, Harrington B, Fadrowski JJ, Sibinga E, Amankwah EK. Correlation between Cosyntropin Stimulation Study and Disease Severity in Children with Fluid- and Catecholamine-Refractory Shock in the Pediatric and Cardiovascular Intensive Care Unit. Horm Res Paediatr 2018; 89:31-37. [PMID: 29151100 DOI: 10.1159/000484561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 10/24/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The cosyntropin stimulation study (CSS) measures the patient's ability to adequately mount a cortisol response. Clinically, CSS results may not be used to guide hydrocortisone use. The objective of this study was to examine how the CSS results are associated with clinical parameters, mortality/disease severity, and use of glucocorticoids in pediatric patients with catecholamine- and fluid-resistant shock. METHODS This was a retrospective cohort study of patients who had a CSS during 2009-2014 in the intensive care unit at a children's hospital. Data collected included clinical variables, mortality, biochemical studies, and glucocorticoid use. PRISM III scores were used to determine the association between CSS results and disease severity. Adequate response to cosyntropin was defined as peak cortisol of 18 µg/dL or higher. RESULTS Of the 76 patients that underwent CSS, 68 (89%) had an adequate response to cosyntropin. There was a positive correlation between peak cortisol and PRISM III score (r = 0.45, r2 = 0.2). Glucocorticoid was administered in 52/76 (68%) despite several patients with normal CSS results. CONCLUSIONS Sicker patients were more likely to have an adequate response to CSS. Clinically, glucocorticoid supplementation was not based on CSS results. Further prospective studies are needed to elucidate if CSS is a valuable clinical tool.
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Affiliation(s)
- Pallavi Iyer
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brittany Harrington
- Garden City Hospital, Michigan State University COM, Garden City, Michigan, USA
| | | | | | - Ernest K Amankwah
- Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
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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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Chen K, Sun Y, Diao Y, Zhang T, Dong W. Hydrogen-rich solution attenuates myocardial injury caused by cardiopulmonary bypass in rats via the Janus-activated kinase 2/signal transducer and activator of transcription 3 signaling pathway. Oncol Lett 2018; 16:167-178. [PMID: 29928398 PMCID: PMC6006345 DOI: 10.3892/ol.2018.8639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 03/14/2018] [Indexed: 12/18/2022] Open
Abstract
The incidence of complications and mortality following open-heart surgery with cardiopulmonary bypass (CPB) is associated with the severity of the myocardial injury that occurs during surgery. Hydrogen-rich solution (HRS) may prevent antioxidant stress and inhibit apoptosis and inflammation. The present study was designed to investigate the effects of HRS on CPB-induced myocardial injury, and to investigate its potential regulation of the Janus-activated kinase 2/signal transducer and activator of transcription 3 (JAK2/STAT3) pathway. The HRS treatment resulted in the significant upregulation of malonyl dialdehyde (MDA) and myeloperoxidase (MPO), whilesuperoxide dismutase (SOD) levels were significantly downregulated, compared with the Sham group (P<0.05). Additionally, HRS treatment improved myocardial injury, and decreased the expression levels of cardiac troponins, heart-type fatty acid binding protein, interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α, MDA and MPO, and increased SOD release in CPB rats (P<0.05). Additionally, in the CPB group without the HRS treatment, the expression levels of B-cell lymphoma (Bcl)-2, JAK2, phospho-JAK2 (p-JAK2), STAT3 and phospho-STAT3 (p-STAT3) were significantly decreased, and Bax was significantly increased, compared with the Sham group (P<0.05). By contrast, compared with the CPB group, the expression levels of B-cell lymphoma 2 (Bcl-2), JAK2, phosphorylated (p)-JAK2, STAT3 and p-STAT3 in the HRS group were significantly increased, and Bcl-2-associated X protein expression was significantly decreased (P<0.05). In JAK2 knockdown experiments using siRNA, HRS treatment following hypoxia/reoxygenation also significantly increased the viability of myocardial cells, decreased the rate of myocardial cell apoptosis, elevated the levels of SOD and suppressed the release of MDA and lactate dehydrogenase in the control siRNA and CPB groups (P<0.05). Furthermore, JAK2 siRNA attenuated these protective effects of HRS (P<0.05 vs. control siRNA, HRS and CPB groups). Additionally, the results demonstrated that the HRS treatment significantly increased the expression levels of p-JAK2, p-STAT3 and Bcl-2 in myocardial cells following hypoxia and decreased Bax expression in the control siRNA and CPB groups (P<0.05). In addition, JAK2 siRNA was determined to attenuate these effects of HRS (P<0.05 vs. control siRNA, HRS and CPB groups). Taken together, these results indicated that HRS may alleviate CPB-induced myocardial injury, inhibit myocardial cell apoptosis and protect myocardial cells through regulation of the JAK2/STAT3 signaling pathway.
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Affiliation(s)
- Keyan Chen
- Department of Laboratory Animal Science, China Medical University, Shenyang, Liaoning 110122, P.R. China
| | - Yingjie Sun
- Department of Anesthesiology, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning 110016, P.R. China
| | - Yugang Diao
- Department of Anesthesiology, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning 110016, P.R. China
| | - Tiezheng Zhang
- Department of Anesthesiology, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning 110016, P.R. China
| | - Wanwei Dong
- Department of Laboratory Animal Science, China Medical University, Shenyang, Liaoning 110122, P.R. China
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Ferraris VA. Exploring molecular mysteries of the adrenal gland: Start with the basics. J Thorac Cardiovasc Surg 2018; 156:707-708. [PMID: 29691046 DOI: 10.1016/j.jtcvs.2018.03.131] [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: 03/24/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Victor A Ferraris
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, A301 Kentucky Clinic, Lexington, Ky.
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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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