Preoperative prediction of pediatric patients with effusions and edema following cardiopulmonary bypass surgery by serological and routine laboratory data

'Are Routine Post-discharge Diuretics Necessary After Pediatric Cardiac Surgery?'

A prospective, one-armed, safety non-inferiority trial with historical controls was performed at a single-center, quaternary, children's hospital. Inclusion criteria were children aged 3 months-18 years after pediatric cardiac surgery resulting in a two-ventricle repair between 7/2020 and 7/2021. Eligible patients were compared with patients from a 5-year historical period (selected using a database search). The intervention was that "regular risk" patients received no diuretics and pre-specified "high risk" patients received 5 days of twice per day furosemide at discharge. 61 Subjects received the intervention. None were readmitted for pleural effusions, though 1 subject was treated for a symptomatic pleural effusion with outpatient furosemide. The study was halted after an interim analysis demonstrated that 4 subjects were readmitted with pericardial effusion during the study period versus 2 during the historical control (2.9% versus 0.2%, P = 0.003). We found no evidence that limited post-discharge diuretics results in an increase in readmissions for pleural effusions. This conclusion is limited as not enough subjects were enrolled to definitively show that this strategy is not inferior to the historical practice. There was a statistically significant increase in readmissions for pericardial effusions after implementation of this study protocol which can lead to serious complications and requires further study before conclusions can be drawn regarding optimal diuretic regimens.

Echocardiographic Screening for Postoperative Pericardial Effusion in Children

Pericardial effusion (PE) after cardiac surgery can be life threatening without timely detection, and the optimal screening method is unknown. We sought to evaluate the role of a surveillance echocardiogram on postoperative day 10 (± 2), determine the incidence of postoperative PE, and identify risk factors. We conducted a retrospective cohort study including all pediatric patients who underwent open heart surgery at a single institution over a 7-month period. To identify risk factors for PE, medical records of patients with PE detected within 6 weeks after surgery (cases) were compared with patients without PE (controls). Of 203 patients, 52 (26%) had PE within 6 weeks; 42 (81%) were trivial-small and 10 (19%) were moderate-large. Twenty-nine (56%) were first detected within 7 days post-operatively, including all cases developing cardiac tamponade (n = 3). An echocardiogram was done 10 (± 2) days post-operatively in 41/52 cases, of which 12/41 (29%) did not have a PE at this time, 24/41 (59%) had a trivial-small PE, and 5/41(12%) had a moderate-large PE; 2 of the latter had no prior detected PE. Closure of an atrial septal defect had the highest incidence of PE (42%). PE cases were associated with postoperative nasopharyngeal detection of a respiratory virus (OR 3.8, p = 0.03). In conclusion, the majority of PE cases were detected within 7 days post-operatively, including all cases subsequently developing cardiac tamponade. Day 10 echocardiography infrequently detected a moderate or large effusion that had previously gone undiagnosed. A positive perioperative nasopharyngeal aspirate for a respiratory virus was associated with postoperative PE.

Influence of factor XIII activity on post-operative transfusion in congenital cardiac surgery-A retrospective analysis

Objectives

Coagulation factor XIII (FXIII) plays a key role in fibrin clot stabilization—an essential process for wound healing following cardiothoracic surgery. However, FXIII deficiency as a risk for post-operative bleeding in pediatric cardiac surgery involving cardiopulmonary bypass (CPB) for congenital heart disease (CHD) is controversially discussed. Thus, as primary outcome measures, we analyzed the association of pre-operative FXIII activity and post-operative chest tube drainage (CTD) loss with transfusion requirements post-operatively. Secondary outcomes included the influence of cyanosis and sex on transfusion.

Methods

Our retrospective analysis (2009–2010) encompassed a single center series of 76 cardio-surgical cases with CPB (0–17 years, mean age 5.61 years) that were post-operatively admitted to our pediatric intensive care unit (PICU). The observational period was 48 hours after cardiac surgery. Blood cell counts and coagulation status, including FXIII activity were routinely performed pre- and post-operatively. The administered amount of blood products and volume expanders was recorded electronically, along with the amount of CTD loss. Uni- and multivariate logistic regression analysis was performed to calculate the associations (odds ratios) of variables with post-operative transfusion needs.

Results

FXIII activities remained stable following CPB surgery. There was no association of pre- and post-operative FXIII activities and transfusion of blood products or volume expanders in the first 48 hours after surgery. Similarly, FXIII showed no association with CTD loss. Cyanosis and female sex were associated with transfusion rates.

Conclusions

Although essentially involved in wound healing and clotting after surgery, FXIII activity does not serve as a valid predictor of post-operative transfusion need.

Association of Preoperative Cell Counts With Outcomes After Operation for Congenital Heart Disease

BACKGROUND

We examined the association of preoperative cell count abnormalities, which have been shown to be associated with outcomes in adult cardiac patients, with morbidity and mortality after operation for congenital heart disease (CHD) in children.

METHODS

We performed a retrospective cohort study on 4,865 children undergoing cardiac operation from 2004 to 2014. Our exposures of interest were presence of preoperative lymphopenia (lymphocyte count ≤ 3,000 cells/μL), thrombocytopenia (platelet count < 150 × 10³/μL), and neutrophilia (neutrophil count ≥ 7,000 cells/μL). Our outcomes of interest were mortality status, postoperative length of stay (LOS), and occurrence of postoperative complications. We performed logistic and linear regressions to determine the associations of preoperative cell counts with mortality, LOS, and complications, adjusting for age, sex, race or ethnicity, presence of a genetic syndrome, and Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality category.

RESULTS

Overall mortality was 2.8%, median LOS was 6 days, and 7.6% of patients had postoperative complications. Lymphopenia was associated with increased odds of postoperative mortality (odds ratio 1.67, 95% confidence interval: 1.15 to 2.43, p = 0.007). Lymphopenia, thrombocytopenia, and neutrophilia were all associated with longer postoperative LOS. Lymphopenia and thrombocytopenia were associated with increased occurrence of postoperative sepsis, and neutrophilia was associated with need for postoperative mechanical circulatory support.

CONCLUSIONS

In children undergoing CHD operation, preoperative lymphopenia is associated with increased in-hospital mortality postoperatively. Preoperative lymphopenia, neutrophilia, and thrombocytopenia are associated with longer postoperative LOS and with development of postoperative complications. Preoperative cell counts may serve as important prognostic markers in preoperative planning for patients with CHD.

Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Fluid Management

OBJECTIVE

In this Consensus Statement, we review the etiology and pathophysiology of fluid disturbances in critically ill children with cardiac disease. Clinical tools used to recognize pathologic fluid states are summarized, as are the mechanisms of action of many drugs aimed at optimal fluid management.

DATA SOURCES

The expertise of the authors and a review of the medical literature were used as data sources.

DATA SYNTHESIS

The authors synthesized the data in the literature in order to present clinical tools used to recognize pathologic fluid states. For each drug, the physiologic rationale, mechanism of action, and pharmacokinetics are synthesized, and the evidence in the literature to support the therapy is discussed.

CONCLUSIONS

Fluid management is challenging in critically ill pediatric cardiac patients. A myriad of causes may be contributory, including intrinsic myocardial dysfunction with its associated neuroendocrine response, renal dysfunction with oliguria, and systemic inflammation with resulting endothelial dysfunction. The development of fluid overload has been associated with adverse outcomes, including acute kidney injury, prolonged mechanical ventilation, increased vasoactive support, prolonged hospital length of stay, and mortality. An in-depth understanding of the many factors that influence volume status is necessary to guide optimal management.

Genetic and clinical risk factors for fluid overload following open-heart surgery

BACKGROUND

Post-operative fluid overload following cardiac surgery is associated with increased morbidity and mortality. We hypothesised that genetic variations and pre-operative clinical factors predispose some patients to post-operative fluid overload.

METHODS

Perioperative variables were collected prospectively for 1026 consecutive adults undergoing open-heart surgery at St. Olavs University Hospital, Norway from 2008-2010. Post-operative fluid overload was defined as a post-operative fluid balance/kg ≥ the 90th percentile of the study population. Genotyping was performed for 31 single-nucleotide polymorphisms related to inflammatory/vascular responses or previously associated with complications following open-heart surgery. Data were analysed using logistic regression modelling, and the findings were internally validated by bootstrapping (n = 100).

RESULTS

Homozygous carriers of the common G allele of rs12917707 in the UMOD gene had a 2.2 times greater risk of post-operative fluid overload (P = 0.005) after adjustment for significant clinical variables (age, duration of cardiopulmonary bypass, and intraoperative red cell transfusion). A genetic risk score including 14 single-nucleotide polymorphisms was independently associated with post-operative fluid overload (P = 0.001). The number of risk alleles was linearly associated with the frequency of fluid overload (odds ratio per risk allele 1.153, 95 % confidence interval 1.056-1.258). Nagelkerke's R(2) increased with 7.5% to a total of 25% for the combined clinical and genetic model. Hemofiltration did not reduce the risk.

CONCLUSION

A common variation in the UMOD gene previously shown to be related to renal function was associated with increased risk of post-operative fluid overload following cardiac surgery. Our findings support a genetic susceptibility to disturbed fluid handling following cardiac surgery.

Postoperative adiponectin levels in pediatric patients undergoing open heart surgery

Background. Adipose tissue is an important endocrine organ that secretes cytokines, including adiponectin, levels of which are negatively correlated with the severity of the inflammatory process. Aim. To assess the time course of adiponectin levels following open heart surgery with cardiopulmonary bypass and its correlation with early postoperative outcomes. Materials and Methods. Blood samples were obtained from 24 children undergoing cardiac surgery and analyzed for adiponectin, C-reactive protein, and other inflammatory markers. Results. Baseline adiponectin levels were negatively correlated with patients' preoperative weight and age. Postoperative adiponectin levels decreased compared to baseline (P = 0.01) and correlated negatively with duration of cardiopulmonary bypass (r = −0.438, P = 0.037), length of stay in the pediatric intensive care unit (r = −0.457, P = 0.025), and the inotropic score (r = −0.471, P = 0.02). Adiponectin levels were positively correlated with sVCAM 1 levels; however, there was no correlation between adiponectin levels and sP selectin, tPA, MCP1, and sCD40. Conclusions. The inflammatory response after open heart surgery with cardiopulmonary bypass is associated with a reduction in adiponectin levels. Prolonged or more complicated surgery induced a more substantial inflammatory process characterized by a significant reduction in adiponectin levels over time and a delayed return to baseline levels.

Results on mining NHANES data: a case study in evidence-based medicine

The National Health and Nutrition Examination Survey (NHANES), administered annually by the National Center for Health Statistics, is designed to assess the general health and nutritional status of adults and children in the United States. Given to several thousands of individuals, the extent of this survey is very broad, covering demographic, laboratory and examination information, as well as responses to a fairly comprehensive health questionnaire. In this paper, we adapt and extend association rule mining and clustering algorithms to extract useful knowledge regarding diabetes and high blood pressure from the 1999-2008 survey results, thus demonstrating how data mining techniques may be used to support evidence-based medicine.

Pleural effusions in children undergoing cardiac surgery

Persistent pleural effusions are a source of significant morbidity and mortality following surgery in congenital heart disease. In this review, we discuss the etiology, pathophysiology, and management of this common complication.

Modulation of the cellular and humoral immune response to pediatric open heart surgery by methylprednisolone

BACKGROUND

With the intention to reduce overshooting immune response, glucocorticoids are frequently administered perioperatively in children undergoing open heart surgery. In a retrospective study we investigated extensively the modulation of the humoral and cellular immune response by methylprednisolone (MP).

METHODS

This study was carried out on blood samples from two groups of children who had undergone surgical correction of atrial or ventricular septal defects, either without (MP⁻, n = 10), or with MP administration (MP+, n = 23, dose median 11 (IQR 10-16) mg kg⁻¹ body weight) before cardiopulmonary bypass (CPB, duration median 42 (IQR 36-65) min). EDTA blood was obtained 24 h preoperatively, after anesthesia, at CPB begin and end, 4, 24, and 48 h after surgery, at discharge and at out-patient follow-up (median 8.2 (IQR 3.3-12.2) months after surgery). Complex blood analysis including clinical chemistry and flow cytometry were performed to monitor humoral immune response, differential blood count, lymphocyte subsets, and the degree of activation of various leukocyte subpopulations.

RESULTS

The patients' postoperative courses and follow-up were uneventful. Release of IL-6 and IL8 was reduced and that of the anti-inflammatory cytokine IL-10 upregulated by MP. Significant increase of circulating neutrophils and monocytes as inflammatory reaction to surgery and CPB contact was detected in both groups. However, invasion of monocytes to the periphery was delayed with MP. CD4+ and CD8+ T-lymphocyte counts were lower with MP treatment. B-lymphocyte count increased significantly after surgery in MP+ but remained constant in MP⁻ group.

CONCLUSIONS

MP treatment partially decreased the pro-inflammatory effect of CPB surgery and induced anti-inflammatory effect on the cellular and humoral level.

Early pleural effusions related to the myocardial injury after open-heart surgery for congenital heart disease

OBJECTIVES

The degree of effusion immediately after cardiopulmonary bypass (CPB) can vary and may reflect several factors including the degree of myocardial injury. We compared the degree of pleural effusions after CPB to the overall myocardial injury as determined by serum cardiac troponin I (cTnI) levels after elective repair of a variety of congenital heart defects, including univentricular surgeries via cavopulmonary shunts.

METHODS

Serum was collected pre-CPB, post-CPB, and daily after that and cTnI level measured. The postoperative pleural effusion was measured each day until the chest tube was removed. Results. The 21 study patients were of average age of 5.5 years (+/-5.6). The duration of chest-tube drainage after open-heart surgery was 4.3 days (+/-3.5) and the amount was 2.4 mL/kg/hour (+/-2.9). For the biventricular repairs, cTnI levels on the postoperative day (POD) 1 best correlated with amount of effusion (n = 16, r = 0.5, P = 0.02) and the average (POD 0-3) cTnI levels with the total duration (n = 16, r = 0.4, P = 0.01) and also the amount (n = 16, r = 0.5, P = 0.02) of effusions. For the cavopulmonary shunts, the post-CBP cTnI level best correlated with the duration (n = 5, r = 0.8, P = 0.02) and amount (n = 5, r = 0.9, P = 0.02) of effusions. A cTnI level on the first postoperative day >or=15 microg/L was associated with effusions >2 days (sensitivity of 81% and specificity of 80%).

CONCLUSION

We found that higher the cTnI released, especially >or=15 microg/L, longer the duration and greater the amount of early pleural effusions for a variety of congenital heart surgeries including cavopulmonary shunts. A number of factors may lead to excessive pleural effusions and the degree of myocardial injury may be one of them.

Incessant pericardial effusion in a 9 year old male responding to infliximab

Recurrent idiopathic pericardial effusion can be a challenging medical problem. Multiple medical interventions may yield minimal improvement. We describe a patient with an incessant pericardial effusion that responded to infliximab. The use of infliximab should be considered in the management of recurrent pericardial effusions resistant to other treatment modalities.

Intra-abdominal and abdominal perfusion pressure in patients undergoing coronary artery bypass graft surgery

BACKGROUND

In 2006, the International Conference of Experts on Intra-abdominal Hypertension defined abdominal perfusion pressure (APP) as the difference between mean arterial pressure (MAP) and intra-abdominal pressure (IAP).The aim of the study was to analyse changes in IAP and APP in patients undergoing elective coronary artery bypass grafting (CABG).

PATIENTS AND METHODS

Fifty patients undergoing CABG with extracorporeal circulation (ECC) and normovolemic haemodilution (NH) under general anaesthesia were studied. IAP and APP were measured during CABG and in the early postoperative period. Changes in IAP and APP were analysed according to degree of normovolemic haemodilution, age, body weight, body mass index (BMI), duration of anaesthesia, surgery, ECC, aorta clamping and other haemodynamic parameters.

RESULTS

The induction of anaesthesia decreased IAP. Extracorporeal circulation resulted in IAP elevation, which was dependent on the degree of blood dilution. At any time point of the postoperative period IAP higher than 12 mmHg was noted in 22 patients (44%). Abdominal perfusion pressure decreased during ECC and on the morning of the first postoperative day. Intra-abdominal pressure strongly correlated with BMI and central venous pressure. The correlation between IAP and APP and other haemodynamic parameters was poor.

CONCLUSIONS

1) The induction of anaesthesia decreased IAP. 2) ECC resulted in an increase in IAP. 3) IAP increased in 44% of patients. 4) IAP strongly correlated with BMI and central venous pressure. 5) CABG with ECC resulted in a decrease in APP. 6) Changes in APP strongly correlated with MAP and poorly correlated with other haemodynamic parameters. 7) The changes in APP demonstrated a double-phase character.

Factors prolonging length of stay in the cardiac intensive care unit following the arterial switch operation

The arterial switch operation has become the preferred procedure for surgical management of transposition, defined on the basis of concordant atrioventricular and discordant ventriculo-arterial connections. We conducted a retrospective evaluation of our experience in 61 infants with this segmental combination, seen from January, 1997, to July, 2003, in order to determine the factors that are associated with a prolonged postoperative course. Factors independently associated with a prolonged postoperative stay in the cardiac intensive care unit included prematurity, difficulty in feeding, capillary leak, need for preoperative inotropic support, and postoperative infectious complications. Future research is warranted designed to minimize the impact of capillary leak and postoperative infectious complications. In addition, based on these results, our practice has evolved to initiate enteral feedings in the preoperative period if feasible, with such enteral feedings resumed as soon as possible following surgery.

Circulating inflammatory mediators and organ dysfunction after cardiovascular surgery with cardiopulmonary bypass: a prospective observational study

Introduction

Cardiovascular surgery with cardiopulmonary bypass (CPB) has improved in past decades, but inflammatory activation in this setting is still unpredictable and is associated with several postoperative complications. Perioperative levels of macrophage migration inhibitory factor (MIF) and other inflammatory mediators could be implicated in adverse outcomes in cardiac surgery.

Methods

Serum levels of MIF, monocyte chemoattractant protein (MCP)-1, soluble CD40 ligand, IL-6 and IL-10 from 93 patients subjected to CPB were measured by enzyme-linked immunosorbent assay and compared with specific and global postoperative organ dysfunctions through multiple organ dysfunction score (MODS) and sequential organ failure assessment (SOFA).

Results

Most of the cytokines measured had a peak of production between 3 and 6 hours after CPB, but maximum levels of MIF occurred earlier, at the cessation of CPB. Among specific organ dysfunctions, the most frequent was hematological, occurring in 82% of the patients. Circulatory impairment was observed in 73.1% of the patients, and 51% of these needed inotropics or vasopressors within the first 24 hours after surgery. The third most frequent dysfunction was pulmonary, occurring in 48.4% of the patients. Preoperative levels of MIF showed a relevant direct correlation with the intensity of global organ dysfunction measured by SOFA (ρ = 0.46, p < 0.001) and MODS (ρ = 0.50, p < 0.001) on the third day after surgery. MCP-1 production was associated with postoperative thrombocytopenia, and MIF was related to the use of a high dose of vasopressors in patients with cardiovascular impairment and also to lower values of the ratio of partial arterial oxygen tension (PaO₂) to fraction of inspired oxygen (FiO₂) registered in the first 24 hours after CPB.

Conclusion

Despite the multifactorial nature of specific or multiple organ dysfunctions, MIF should be explored as a predicting factor of organ dysfunction, or even as a potential therapeutic target in decreasing postoperative complications.

Transient Th1/Th2 disbalance indicates postoperative effusions and edema after cardiopulmonary bypass in children

BACKGROUND

Cardiac surgery with cardiopulmonary bypass (CPB) induces substantial release of IL-10, indicating increased Th2 cell response. Therefore, in this study, we wanted to verify if this response is due to CPB or surgical trauma, and to study its relation to postoperative effusions and edema (POEE) in children.

METHODS

Th1/Th2 reaction was monitored in children undergoing cardiovascular surgery with (n = 75) and without CPB (n = 29).

RESULTS

Surgery with CPB compared to surgery without CPB induced a transient shift towards Th2. Elevated Th2 response was related to increased vascular permeability and POEE.

CONCLUSION

The immune suppression/Th2 response is typical for CPB, and at intermediate level is tolerable but at high level could be adverse for the patients.

Capillary leak syndrome in children with C4A-deficiency undergoing cardiac surgery with cardiopulmonary bypass: a double-blind, randomised controlled study

BACKGROUND

Capillary leak syndrome is a life-threatening complication after cardiopulmonary bypass (CPB), with an incidence of about 4-37% in children worldwide. On the basis of previous results, we undertook a randomised controlled study to investigate the priming with plasma rich in the C4A isotype of complement component 4 on the incidence of capillary leak syndrome in children with C4A deficiency.

METHODS

In a hospital in Wuhan, China, we randomly assigned 116 neonates, infants, and children lacking complement component C4A to receive C4A-free or C4A-rich plasma priming (n=58 each, 20 mL/kg). The primary outcome was capillary leak syndrome, identified as an increased transvascular escape rate of Evans blue dye from plasma. Concentrations of activated complement components C4 and C3, inflammatory mediators interleukin 6, interleukin 8, tumour necrosis factor (TNF) alpha, plasma protein, and PaO2/F(I)O2 ratios (ratio of the partial arterial pressure of oxygen to the fractional concentration of oxygen in inspired air) were measured before and 4 h after CPB. Analysis was by intention to treat.

FINDINGS

Three (5%) patients given C4A-rich plasma priming had capillary leak syndrome compared with 56 (97%) given C4A-free plasma (p<0.0001). At 4 h after CPB, activated C4, interleukin 6, interleukin 8, and TNFalpha concentrations were higher, whereas PaO2/F(I)O2 ratios and plasma protein concentrations were significantly lower in the C4A-free group than changes in the C4A-rich group. Activated C3 rose equally in both groups. Activated C4 significantly correlated with interleukin 6, interleukin 8, and TNFalpha concentrations; PaO2/F(I)O2 ratios; and the escape rate of Evans blue dye at 4 h after CPB. Two patients in the C4A-free group died of respiratory and renal failure on day 3 after CPB.

INTERPRETATION

In paediatric patients with C4A deficiency, C4A-rich plasma priming reduces the incidence of CPB-related capillary leak syndrome by blocking the activated C4 increase and attenuating the systemic inflammatory response after CPB.

Pre-procedural expression of Mac-1 and LFA-1 on leukocytes for prediction of late restenosis and their possible correlation with advanced coronary artery disease

BACKGROUND

The activation status of the inflammatory system has been suggested to play an important role in predicting restenosis. Activation of leukocyte adhesion molecules occur after coronary intervention and the level of activation correlates to restenosis. However, little is known about the specific role of adhesion molecules before intervention. The purpose of this study concerned the search for differences in the expression level of selected adhesion molecules to identify suitable tools for the pre-procedural identification of restenosis patients prior to angioplasty.

METHODS

Blood samples of 31 patients undergoing elective coronary angiography were obtained just before intervention. Seven healthy volunteers were also enrolled. Surface expression of leukocyte adhesion molecules Mac-1 (CD11b/CD18), LFA-1 (CD11a/CD18), L-Selectin (CD62L), ICAM-1 (CD54), and MHC-II (HLA-DR) were assessed by flow cytometry. Patients with a successful angioplasty received a follow-up angiography after six months.

RESULTS

According to the clinical and angiographic data, patients were divided into four groups: control (N = 14), no restenosis (N = 11), restenosis (N = 4), and advanced coronary artery disease (CAD, N = 9). The restenosis group and the advanced CAD group showed higher expression of Mac-1 and LFA-1 on monocytes and neutrophils compared to the other groups. Using the pre-procedural expression levels, patients with restenosis could be predicted by discriminant analysis with CD11a, CD11b, and CD18 (average recognition index = 95.5%).

CONCLUSIONS

The data of this pilot study indicate that pre-procedural activation status of CD11a and CD11b may play a role in the subsequent development of restenosis. Moreover, CD11a, CD11b, and CD18 may be helpful as indicators for the progression of CAD.

The impact of the pro- and anti-inflammatory immune response on ventilation time after cardiac surgery

BACKGROUND

Cardiac surgery using cardiopulmonary bypass (CPB) may induce a systemic inflammatory response syndrome (SIRS), which is associated with an increased risk of postoperative morbidity and mortality. The intention of this pilot study was to investigate the influence of the pro- and anti-inflammatory cytokine responses as well as of released adhesion molecules and endotoxin on the time requirements for assisted postoperative respiration following CPB surgery.

METHODS

One hundred consecutive patients undergoing elective coronary artery bypass grafting (CABG) using CPB were prospectively investigated. Blood levels of cytokines, adhesion molecules, and endotoxins were serially measured at four time points perioperatively.

RESULTS

All patients survived the observation period. Eighty-five patients were uneventful (group 1), whereas 15 patients required prolonged ventilation (34.8 +/- 9.2 h; group 2). All patients developed a pro-inflammatory and a compensatory anti-inflammatory cytokine response. An endotoxin liberation was found in parallel. The prediction of prolonged respirator dependence may be possible at completion of surgery using a combined data pattern analysis, including interleukin (IL)-6, IL-8, IL-4, endotoxins, vascular cell adhesion molecule (VCAM)-1, age, and cross clamp (x-clamp) time. Using arbitrary cutoff points improved sensitivity (0.92), specificity (0.90), positive prediction (0.87), and negative prediction (0.85) (all P < 0.02), and the ODD ratio (2.1) was found.

CONCLUSIONS

Cardiac surgery and CPB induces both a pro- and anti-inflammatory immune response. The use of a data pattern instead of several individual parameters seems advantageous for individualized predictions on postoperative recovery in CPB surgery.

Protein-losing enteropathy after fontan surgery: is assessment of risk patients with immunological data possible?

BACKGROUND

Protein-losing enteropathy (PLE) is a late complication of the Fontan type surgery for univentricular heart characterized by massive enteric protein loss. The pathogenesis of PLE is not fully understood, and it is unclear why the onset of PLE varies widely and occurs months or even years after surgery. Besides characteristic laboratory findings, a typical cellular feature concerns the almost selective loss of CD4(+) lymphocytes at an only slightly changed CD8(+) lymphocyte count. The present pilot study aimed to test whether immunological or laboratory parameters differ in patients at risk for PLE.

METHODS

From children (n = 15) with Fontan type circulation, extensive cellular, humoral, and clinical laboratory data were analyzed. Patients without enteric protein loss (group I, n = 8), with transient phases of enteric protein loss in the absence of gastric infections (group II, n = 6), and one PLE patient (group III) were distinguished. The 90 data columns obtained in phases with normal serum protein levels were compared.

RESULTS

Clear differences were apparent between patients prior to PLE onset (group III), patients that in at least one occasion exhibited PLE signs (group II), and patients without detectable PLE signs (group I). The most discriminatory parameters between the three patient groups were NK and CD8(+)TCRalphabeta(+), CD8(+)TCRgammadelta(+) cell counts, including sL-selectin, IgE, and Ca(2+) (average recognition index = 91.5%, negative/positive prediction/sensitivity/specificity > 83%).

CONCLUSIONS

The results of this study seem to provide access to the early detection of PLE patients.

Increased predictive value of parameters by fuzzy logic-based multiparameter analysis

BACKGROUND

A recent study on postoperative effusions and edema was used to demonstrate the potential of fuzzy techniques in multiparameter data analysis. In this study, more than 50 parameters of 75 patients were collected and examined for correlations between some of the parameters and the later development of complications.

METHODS

We employed a rule-based fuzzy-logic system in order to combine the diagnostic values of single parameters. The advantage of fuzzy sets is that they substitute sharp cut-off values with a smooth transition from one property to another. Therefore, there is no decision of "either-or" but rather a graded assessment of "more or less", which is often more suitable for a problem.

RESULTS

The fuzzy combination of parameters led to a large increase of sensitivity and specificity when compared with the best single parameter. This increase was achieved by taking a close look at the parameters. A newly created parameter, relative weight, turned out to be very powerful.

CONCLUSIONS

Fuzzy techniques can increase the discriminating power of classical statistical tools. In addition, results obtained by fuzzy analysis are highly interpretable. A combination of the CLASSIF1 algorithm for the identification of the most relevant parameters, followed by fuzzy analysis, represents a powerful tool for the handling of large amounts of multiparameter data.