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Yan S, Gao S, Lou S, Yu C, Sun X, Qian X, Ji B. Does methylprednisolone provide protective effect in total aortic arch replacement requiring hypothermia circulatory arrest and selective cerebral perfusion? Perfusion 2023; 38:1384-1392. [PMID: 35786218 DOI: 10.1177/02676591221113650] [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: 11/17/2022]
Abstract
BACKGROUND Glucocorticoids (GC)were applied in total aortic arch replacement (TAAR) at various dosages in many centers, but with limited evidence. METHODS The retrospective study was aimed to evaluate whether methylprednisolone was associated with better postoperative outcomes in patients undergoing TAAR. Patients undergoing TAAR with moderate hypothermia and selective cerebral perfusion between 2017.1 to 2018.12 in Fuwai hospital were classified into three groups according to doses of methylprednisolone given in the surgery: large-GC group (1500-3000 mg); medium-GC group (500-1000 mg) and no-GC group (0 mg). Postoperative outcomes were compared among three groups. Multivariable analysis was performed to identify the association of methylprednisolone with outcomes. RESULTS Three hundred twenty-eight patients were enrolled. Two hundred twenty-eight were in the large-GC group, 34 were in the medium-GC group, and 66 were in the no-GC group. The incidences of major adverse outcomes in large-GC, medium-GC and no-GC groups were 22.8%, 17.6% and 18.2%, respectively, with no statistical difference. A significant difference was observed in post-cardiopulmonary bypass (CPB) fresh frozen plasma (FFP) transfusion (p < .001) and chest drainage volume (p < .001). Multivariable analysis demonstrated that methylprednisolone was not associated with better outcomes (p = .455), while large doses of methylprednisolone were significantly associated with excessive chest drainage (over 2000 mL) [OR (99% CI) 4.282 (1.66-11.044), p < .001] and excessive post-CPB FFP transfusion (over 400 mL) [OR (99% CI) 2.208 (1.027-4.747), p = .008]. CONCLUSIONS Large doses of methylprednisolone (1500-3000 mg) did not show a protective effect in TAAR with moderate hypothermia arrest plus selective cerebral perfusion and might increase postoperative bleeding and FFP transfusion.
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Affiliation(s)
- Shujie Yan
- Department of Cardiopulmonary Bypass, State key laboratory of Cardiovascular Medicine, Fuwai Hospital, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Sizhe Gao
- Department of Cardiopulmonary Bypass, State key laboratory of Cardiovascular Medicine, Fuwai Hospital, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Song Lou
- Department of Cardiopulmonary Bypass, State key laboratory of Cardiovascular Medicine, Fuwai Hospital, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Cardiovascular surgery, State key laboratory of Cardiovascular Medicine, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular surgery, State key laboratory of Cardiovascular Medicine, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Xiangyang Qian
- Department of Cardiovascular surgery, State key laboratory of Cardiovascular Medicine, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, State key laboratory of Cardiovascular Medicine, Fuwai Hospital, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
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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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Fudulu DP, Schadenberg A, Gibbison B, Jenkins I, Lightman S, Angelini GD, Stoica S. Corticosteroids and Other Anti-Inflammatory Strategies in Pediatric Heart Surgery: A National Survey of Practice. World J Pediatr Congenit Heart Surg 2018; 9:289-293. [PMID: 29692229 DOI: 10.1177/2150135118762392] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The role of steroids to mitigate the deleterious effects of pediatric cardiopulmonary bypass (CPB) remains a matter of debate; therefore, we aimed to assess preferences in administering corticosteroids (CSs) and the use of other anti-inflammatory strategies in pediatric cardiac surgery. METHODS A 19-question survey was distributed to consultants in pediatric cardiac anesthesia from 12 centers across the United Kingdom and Ireland. RESULTS Of the 37 respondents (37/60, 62%), 24 (65%) use CSs, while 13 (35%) do not use steroids at all. We found variability within 5 (41%) of the 12 centers. Seven consultants (7/24, 29%) administer CSs in every case, while 17 administer CSs in selected cases only (17/24, 71%). There was variability in the dose of steroid administration. Almost all consultants (23/24, 96%) administer a single dose at induction, and one administers a two-dose regimen (1/24, 4%). There was variability in CS indications. Most consultants (24/37, 66%) use modified ultrafiltration at the conclusion of CPB. Fifteen consultants (15/32, 47%) report the use of aprotinin, while only 3 use heparin-coated circuits (3/24, 9%). CONCLUSIONS We found wide variability in practice in the administration of CSs for pediatric cardiac surgery, both within and between units. While most anesthetists administer CSs in at least some cases, there is no consensus on the type of steroid, the dose, and at which patient groups this should be directed. Modified ultrafiltration is still used by most of the centers. Almost half of consultants use aprotinin, while heparin-coated circuits are infrequently used.
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Affiliation(s)
- Daniel P Fudulu
- 1 Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom.,2 Henry Welcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Alvin Schadenberg
- 3 Pediatric Cardiac Anesthesia and Intensive Care, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Ben Gibbison
- 4 Cardiac Anesthesia and Intensive Care, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Ian Jenkins
- 3 Pediatric Cardiac Anesthesia and Intensive Care, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
| | - Stafford Lightman
- 2 Henry Welcome Laboratories for Integrative Neuroscience and Metabolism, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Gianni D Angelini
- 1 Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | - Serban Stoica
- 5 Department of Congenital Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom
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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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Endo Y, Shoji N, Shimada Y, Kasahara E, Iikubo M, Sato T, Sasano T, Ichikawa H. Prednisolone induces microglial activation in the subnucleus caudalis of the rat trigeminal sensory complex. Cell Mol Neurobiol 2014; 34:95-100. [PMID: 24077857 DOI: 10.1007/s10571-013-9990-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 09/17/2013] [Indexed: 12/20/2022]
Abstract
Prednisolone is a member of synthetic glucocorticoids which are widely used to treat chronic inflammatory diseases. In this study, neuronal degeneration and cell death, and glial reaction were investigated in the rat trigeminal ganglion (TG) and brainstem after subcutaneous injection of prednisolone for 7 days. Expression of c-Jun activating transcription factor 3 and caspase-3 was absent or infrequent in the TG, and cranial sensory and motor nuclei of saline- and prednisolone-treated animals. In these animals, distribution of calcitonin gene-related peptide-immunoreactive (-IR) neurons and nerve fibers was similar in the brainstem. In addition, the number of Iba1- and glial fibrillary acidic protein (GFAP)-IR cells with some processes in the brainstem was barely affected by prednisolone treatment. However, the treatment increased ramification of Iba1-IR processes in the subnucleus caudalis of the trigeminal sensory complex. Prednisolone scarcely influenced the morphology of GFAP-IR cells in the brainstem. Expression of p38 mitogen-activated protein kinase was very rare in the brainstem of saline- and prednisolone-treated animals. The present study suggests that microglia are activated by prednisolone in the subnucleus caudalis of the trigeminal sensory complex. The glucocorticoid may affect nociceptive transmission in the brainstem.
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Nakamura S, Kusaka T, Yasuda S, Ueno M, Miki T, Koyano K, Nakamura M, Okada H, Okazaki K, Isobe K, Itoh S. Cerebral blood volume combined with amplitude-integrated EEG can be a suitable guide to control hypoxic/ischemic insult in a piglet model. Brain Dev 2013. [PMID: 23199679 DOI: 10.1016/j.braindev.2012.10.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The purposes of this study are to compare two hypoxic/ischemic (H/I) insults using amplitude-integrated EEG (aEEG), alone or combined with cerebral blood volume (CBV), as a guide to control hypoxia and to determine which protocol most effectively produces a consistent degree of survivable neuropathological damage in a newborn piglet model of perinatal asphyxia. METHODS Eighteen piglets were subjected to H/I insult of 20-min low aEEG (LAEEG). After the 20-min, the aEEG group was maintained with low mean arterial blood pressure for 10min. The procedure for the aEEG plus CBV group was stopped if CBV became the rated value after 20min of LAEEG. We measured changes in CBV using a near-infrared time-resolved spectroscopy (TRS) and cerebral electrocortical activity using aEEG until 6h post-insult. At 5days post insult, the piglets' brains were perfusion-fixed and stained with hematoxylin/eosin. Piglets were grouped as undamaged or damaged; piglets that did not survive to 5days were grouped separately as dead. RESULTS Among surviving piglets, CBV combined with aEEG resulted in significantly greater percentage of damaged piglets than aEEG alone. CONCLUSIONS We conclude that combining CBV with aEEG may be a more effective guide to control H/I insult in a newborn piglet model than aEEG alone.
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Affiliation(s)
- Shinji Nakamura
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
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Lee JK, Blaine Easley R, Brady KM. Neurocognitive monitoring and care during pediatric cardiopulmonary bypass-current and future directions. Curr Cardiol Rev 2011; 4:123-39. [PMID: 19936287 PMCID: PMC2779352 DOI: 10.2174/157340308784245766] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Revised: 12/17/2007] [Accepted: 12/21/2007] [Indexed: 11/22/2022] Open
Abstract
Neurologic injury in patients with congenital heart disease remains an important source of morbidity and mortality. Advances in surgical repair and perioperative management have resulted in longer life expectancies for these patients. Current practice and research must focus on identifying treatable risk factors for neurocognitive dysfunction, advancing methods for perioperative neuromonitoring, and refining treatment and care of the congenital heart patient with potential neurologic injury. Techniques for neuromonitoring and future directions will be discussed.
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Affiliation(s)
- Jennifer K Lee
- Departments of Anesthesiology/Critical Care Medicine and Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Schubert S, Gerlach F, Stoltenburg-Didinger G, Burmester T, Hankeln T, Boettcher W, Wehsack A, Hübler M, Berger F, Abdul-Khaliq H. Cerebral expression of neuroglobin and cytoglobin after deep hypothermic circulatory arrest in neonatal piglets. Brain Res 2010; 1356:1-10. [DOI: 10.1016/j.brainres.2010.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Revised: 06/29/2010] [Accepted: 08/03/2010] [Indexed: 12/26/2022]
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Demir T, Demir H, Tansel T, Kalko Y, Tireli E, Dayioglu E, Barlas S, Onursal E. Influence of Methylprednisolone on Levels of Neuron-Specific Enolase in Cardiac Surgery: A Corticosteroid Derivative to Decrease Possible Neuronal Damage. J Card Surg 2009; 24:397-403. [DOI: 10.1111/j.1540-8191.2009.00842.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Pearl JM, Plank DM, McLean KM, Wagner CJ, Duffy JY. Glucocorticoids improve calcium cycling in cardiac myocytes after cardiopulmonary bypass. J Surg Res 2009; 167:279-86. [PMID: 19726057 DOI: 10.1016/j.jss.2009.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Revised: 04/28/2009] [Accepted: 05/01/2009] [Indexed: 01/08/2023]
Abstract
BACKGROUND Glucocorticoids can reduce myocardial dysfunction associated with ischemia and reperfusion injury following cardiopulmonary bypass (CPB) and circulatory arrest. The hypothesis was that maintenance of cardiac function after CPB with methylprednisolone therapy results, in part, from preservation of myocyte calcium cycling. METHODS Piglets (5-7 kg) underwent CPB and 120 min of hypothermic circulatory arrest with (CPB-GC) or without (CPB) methylprednisolone (30 mgkg(-1)) administered 6h before and at CPB. Controls (No-CPB) did not undergo CPB or receive glucocorticoids (n=6 per treatment). Myocardial function was monitored in vivo for 120 min after CPB. Calcium cycling was analyzed using rapid line-scan confocal microscopy in isolated, fluo-3-AM-loaded cardiac myocytes. Phospholamban phosphorylation and sarco(endo)plasmic reticulum calcium-ATPase (SERCA2a) protein levels were determined by immunoblotting of myocardium collected 120 min after CPB. Calpain activation in myocardium was measured by fluorometric assay. RESULTS Preload recruitable stroke work in vivo 120 min after reperfusion decreased from baseline in CPB (47.4±12 versus 26.4±8.3 slope of the regression line, P<0.05), but was not different in CPB-GC (41±8.1 versus 37.6±2.2, P=0.7). In myocytes isolated from piglets, total calcium transient time remained unaltered in CPB-GC (368±52.5 ms) compared with controls (434.5±35.3 ms; P=0.07), but was prolonged in CPB myocytes (632±83.4 ms; P<0.01). Calcium transient amplitude was blunted in myocytes from CPB (757±168 nM) compared with controls (1127±126 nM, P<0.05) but was maintained in CPB-GC (1021±155 nM, P>0.05). Activation of calpain after CPB was reduced with glucocorticoids. Phospholamban phosphorylation and SERCA2a protein levels in myocardium were decreased in CPB compared with No-CPB and CPB-GC (P<0.05). CONCLUSIONS The glucocorticoid-mediated improvement in myocardial function after CPB might be due, in part, to prevention of calpain activation and maintenance of cardiac myocyte calcium cycling.
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Affiliation(s)
- Jeffrey M Pearl
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Schmitt KRL, Kern C, Berger F, Ullrich O, Hendrix S, Abdul-Khaliq H. Methylprednisolone attenuates hypothermia- and rewarming-induced cytotoxicity and IL-6 release in isolated primary astrocytes, neurons and BV-2 microglia cells. Neurosci Lett 2006; 404:309-14. [PMID: 16860472 DOI: 10.1016/j.neulet.2006.05.064] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 04/18/2006] [Accepted: 05/27/2006] [Indexed: 10/24/2022]
Abstract
Brain protection is crucial during neonatal and pediatric cardiac surgery. The major methods for brain protection are the administration of steroids and deep hypothermia. Therefore, we have investigated the impact of methylprednisolone (MP) administration and deep hypothermia on neonatal mouse astrocytes, neurons and BV-2 microglia cells. Brain cells were pretreated with MP (100 mM) and incubated according to a deep hypothermia protocol mimicking temperature changes during cardiac surgery in children: deep hypothermia (2 h at 17 degrees C, phase 1), slow rewarming (2 h up to 37 degrees C, phase 2), and normothermia (20 h at 37 degrees C, phase 3). In all brain-related cell types cytotoxicity was investigated as well as the release of the pro-inflammatory cytokine interleukin-6 (IL-6), which plays a major role in neuroprotection and neuroregeneration. Deep hypothermia induces substantial cytotoxicity and the secretion of IL-6 by astrocytes, BV-2 microglia cells and neurons. MP administration has no influence on the cell survival and IL-6 release of normothermic astrocytes, BV-2 microglia cells and neurons, while hypothermia-induced cytotoxicity and IL-6 secretion are significantly suppressed by MP. These data suggest that MP increases cell survival after deep hypothermia but also suppresses important neuroprotective and regenerative processes induced by IL-6. Hence, more specific immune modulation than that provided by MP may be needed to protect the brain during neonatal and pediatric cardiac surgery.
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Affiliation(s)
- Katharina R L Schmitt
- Department for Congenital Heart Disease and Pediatric Cardiology, German Heart Institute Berlin, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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