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Thorlacius EM, Keski-Nisula J, Vistnes M, Ojala T, Molin M, Synnergren M, Romlin BS, Ricksten SE, Wåhlander H, Castellheim AG. High-sensitive troponinT, interleukin-8, and interleukin-6 link with post-surgery risk in infant heart surgery. Acta Anaesthesiol Scand 2024. [PMID: 38531618 DOI: 10.1111/aas.14405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND This study focuses on biomarkers in infants after open heart surgery, and examines the association of high-sensitive troponin T (hs-cTnT), interleukin-6 (IL-6), and interleukin-8 (IL-8) with postoperative acute kidney injury (AKI), ventilatory support time and need of vasoactive drugs. METHODS Secondary exploratory study from a double-blinded clinical randomized trial (Mile-1) on 70 infants undergoing open heart surgery with cardiopulmonary bypass (CPB). In this sub-study, the entire study population was examined without considering the study drugs. The biomarkers' peak concentration (highest concentration at 2 or 6 h post-CPB) were used for statistical analyses. RESULTS Peak IL-8, hs-cTnT, and IL-6 occurred at 2 h post-CPB for 96%, 79%, and 63% of the patients, respectively. The odds ratio of developing AKI2-3 for IL-6 > 293 pg/mL was 23.4 (95% CI 5.3;104.0), for IL-8 > 100 pg/mL it was 11.5 (3.0;44.2), and for hs-cTnT >5597 pg/mL it was 6.1 (1.5; 24.5). In more than two third of the patients with the highest peak concentrations of IL-8, IL-6, and hs-cTnT, there was a need for ventilatory support for >24 h and use of vasoactive drugs at 24 h post-CPB, while in less than one third of the patients with the lowest peak concentrations of IL-8 and hs-cTnT such requirements were observed. CONCLUSIONS The peak biomarker concentrations and CPB-time strongly predicted AKI2-3, with IL-6 and IL-8 emerging as strongest predictors. Furthermore, our findings suggest that measuring hs-cTnT and IL-8 just 2 h post-CPB-weaning may assist in identifying infants suitable for early extubation and highlight those at risk of prolonged ventilation.
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Affiliation(s)
- Elin M Thorlacius
- Department of Anesthesiology and Intensive Care medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Juho Keski-Nisula
- Department of Anesthesia and Intensive Care, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Maria Vistnes
- Department of Internal Medicine, Diakonhjemmet Hospital and Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Tiina Ojala
- Department of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | | | - Mats Synnergren
- Department of Pediatric Thoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Birgitta S Romlin
- Department of Anesthesiology and Intensive Care medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Håkan Wåhlander
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Pediatric Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Albert Gyllencreutz Castellheim
- Department of Anesthesiology and Intensive Care medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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Jahnukainen T, Rautiainen P, Tainio J, Pätilä T, Salminen JT, Keski-Nisula J. Renal function and inflammatory response in neonates undergoing cardiac surgery with or without antegrade cerebral perfusion-a post hoc analysis. Ann Card Anaesth 2021; 24:434-440. [PMID: 34747750 PMCID: PMC8617397 DOI: 10.4103/aca.aca_183_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Cardiopulmonary bypass (CPB) may lead to tissue hypoxia, inflammatory response, and risk for acute kidney injury (AKI). We evaluated the prevalence of AKI and inflammatory response in neonates undergoing heart surgery requiring CPB with or without antegrade cerebral perfusion (ACP). Methods: Forty neonates were enrolled. The patients were divided into two groups depending on the use of ACP. AKI was classified based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Inflammatory response was measured using plasma concentrations of interleukins 6 (IL-6) and 10 (IL-10), white blood cell count (WBC), and C-reactive protein (CRP). Results: Eight patients (20%) experienced AKI: five (29%) in the ACP group and three (13%) in the non-ACP group (P = 0.25). Postoperative peak plasma creatinine and urine neutrophil gelatinase-associated lipocalin were significantly higher in the ACP group than in the non-ACP group [46.0 (35.0–60.5) vs 37.5 (33.0-42.5), P = 0.044 and 118.0 (55.4–223.7) vs 29.8 (8.1–109.2), P = 0.02, respectively]. Four patients in the ACP group and one in the non-ACP group required peritoneal dialysis (P = 0.003). Postoperative plasma IL-6, IL-10, and CRP increased significantly in both groups. There were no significant differences between the ACP and non-ACP groups in any of the inflammatory parameters measured. Conclusions: No significant difference in the AKI occurrence or inflammatory response related to CPB modality could be found. In our study population, inflammation was not the key factor leading to AKI. Due to the limited number of patients, these findings should be interpreted with caution.
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Affiliation(s)
- Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paula Rautiainen
- Department of Anesthesia and Intensive Care, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juuso Tainio
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tommi Pätilä
- Department of Pediatric Surgery, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jukka T Salminen
- Department of Pediatric Surgery, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juho Keski-Nisula
- Department of Anesthesia and Intensive Care, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Thorlacius EM, Vistnes M, Ojala T, Keski-Nisula J, Molin M, Romlin BS, Synnergren M, Ricksten SE, Wåhlander H, Castellheim A. Levosimendan Versus Milrinone and Release of Myocardial Biomarkers After Pediatric Cardiac Surgery: Post Hoc Analysis of Clinical Trial Data. Pediatr Crit Care Med 2021; 22:e402-e409. [PMID: 33739957 DOI: 10.1097/pcc.0000000000002712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We compared the effect of two inodilators, levosimendan and milrinone, on the plasma levels of myocardial injury biomarkers, that is, high-sensitivity troponin T and heart-type fatty acid binding protein, and on N-terminal prohormone of brain natriuretic peptide as a biomarker of ventricular function. We hypothesized that levosimendan could attenuate the degree of myocardial injury when compared with milrinone. DESIGN A post hoc, nonprespecified exploratory secondary analysis of the Milrinone versus Levosimendan-1 trial (ClinicalTrials.gov Identifier: NCT02232399). SETTING Two pediatric tertiary university hospitals. PATIENTS Infants 1-12 months old, diagnosed with ventricular septal defect, complete atrioventricular septal defect, or Tetralogy of Fallot undergoing corrective surgery with cardiopulmonary bypass. INTERVENTIONS Seventy patients received a loading dose of either levosimendan or milrinone at the start of cardiopulmonary bypass followed by an infusion of the respective drug, which continued for 26 hours. MEASUREMENTS AND MAIN RESULTS Plasma levels of the three cardiac biomarkers were measured prior to the initiation of cardiopulmonary bypass and 2, 6, and 24 hours after weaning from cardiopulmonary bypass. In both groups, the levels of high-sensitivity troponin T and heart-type fatty acid binding protein were highest at 2 hours post cardiopulmonary bypass, whereas the highest level of N-terminal prohormone of brain natriuretic peptide occurred at 24 hours post cardiopulmonary bypass. There was no significant difference in the biomarkers' plasma levels between the study groups over time. Neither was there a significant difference in the postoperative peak plasma levels of the cardiac biomarkers. CONCLUSIONS In this post hoc analysis of the MiLe-1 trial, there was no demonstrable difference in the postoperative cardiac biomarker profile of myocardial injury and ventricular function when comparing infants managed in the perioperative period with levosimendan versus milrinone.
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Affiliation(s)
- Elin M Thorlacius
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Vistnes
- Department of Internal Medicine, Diakonhjemmet Hospital and Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Tiina Ojala
- Department of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Juho Keski-Nisula
- Department of Anesthesia and Intensive Care, Children's Hospital, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | | | - Birgitta S Romlin
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Synnergren
- Department of Pediatric Thoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Håkan Wåhlander
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Pediatric Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Albert Castellheim
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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Kaskinen AK, Keski-Nisula J, Martelius L, Moilanen E, Hämäläinen M, Rautiainen P, Andersson S, Pitkänen-Argillander OM. Lung Injury After Neonatal Congenital Cardiac Surgery Is Mild and Modifiable by Corticosteroids. J Cardiothorac Vasc Anesth 2021; 35:2100-2107. [PMID: 33573926 DOI: 10.1053/j.jvca.2021.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/04/2021] [Accepted: 01/11/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The present study was performed to determine whether lung injury manifests as lung edema in neonates after congenital cardiac surgery and whether a stress-dose corticosteroid (SDC) regimen attenuates postoperative lung injury in neonates after congenital cardiac surgery. DESIGN A supplementary report of a randomized, double-blinded, placebo-controlled clinical trial. SETTING A pediatric tertiary university hospital. PARTICIPANTS Forty neonates (age ≤28 days) undergoing congenital cardiac surgery with cardiopulmonary bypass. INTERVENTIONS After anesthesia induction, patients were assigned randomly to receive intravenously either 2 mg/kg methylprednisolone or placebo b, which was followed by hydrocortisone or placebo bolus six hours after weaning from CPB for five days as follows: 0.2 mg/kg/h for 48 hours, 0.1 mg/kg/h for the next 48 hours, and 0.05 mg/kg/h for the following 24 hours. MEASUREMENTS AND MAIN RESULTS The chest radiography lung edema score was lower in the SDC than in the placebo group on the first postoperative day (POD one) (p = 0.03) and on PODs two and three (p = 0.03). Furthermore, a modest increase in the edema score of 0.9 was noted in the placebo group, whereas the edema score remained at the preoperative level in the SDC group. Postoperative dynamic respiratory system compliance was higher in the SDC group until POD three (p < 0.01). However, postoperative oxygenation; length of mechanical ventilation; and tracheal aspirate biomarkers of inflammation and oxidative stress, namely interleukin-6, interleukin-8, resistin, and 8-isoprostane, showed no differences between the groups. CONCLUSIONS The SDC regimen reduced the development of mild and likely clinically insignificant radiographic lung edema and improved postoperative dynamic respiratory system compliance without adverse events, but it failed to improve postoperative oxygenation and length of mechanical ventilation.
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Affiliation(s)
- Anu K Kaskinen
- Division of Pediatric Nephrology and Transplantation, Children's Hospital and Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Juho Keski-Nisula
- Department of Anesthesia and Intensive Care, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Laura Martelius
- Department of Radiology, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eeva Moilanen
- The Immunopharmacology Research Group, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Mari Hämäläinen
- The Immunopharmacology Research Group, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Paula Rautiainen
- Department of Anesthesia and Intensive Care, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sture Andersson
- Children's Hospital and Pediatric Research Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Olli M Pitkänen-Argillander
- Division of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Thorlacius EM, Wåhlander H, Ojala T, Ylänen K, Keski-Nisula J, Synnergren M, Romlin BS, Ricksten SE, Castellheim A. Levosimendan Versus Milrinone for Inotropic Support in Pediatric Cardiac Surgery: Results From a Randomized Trial. J Cardiothorac Vasc Anesth 2020; 34:2072-2080. [DOI: 10.1053/j.jvca.2020.02.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 12/23/2022]
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Keski-Nisula J, Arvola O, Jahnukainen T, Andersson S, Pesonen E. Reduction of Inflammation by High-Dose Methylprednisolone Does not Attenuate Oxidative Stress in Children Undergoing Bidirectional Glenn Procedure With or Without Aortic Arch or Pulmonary Arterial Repair. J Cardiothorac Vasc Anesth 2020; 34:1542-1547. [PMID: 32037273 DOI: 10.1053/j.jvca.2019.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/30/2019] [Accepted: 10/06/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Corticosteroids attenuate an inflammatory reaction in pediatric heart surgery. Inflammation is a source of free oxygen radicals. Children with a cyanotic heart defect are prone to increased radical stress during heart surgery. The authors hypothesized that high-dose methylprednisolone reduces inflammatory reaction and thereby also oxidative stress in infants with a univentricular heart defect undergoing the bidirectional Glenn procedure. DESIGN A double-blind, placebo-controlled, randomized clinical trial. SETTING Operating room and pediatric intensive care unit of a university hospital. PARTICIPANTS The study comprised 29 infants undergoing the bidirectional Glenn procedure with or without aortic arch or pulmonary arterial repair. INTERVENTIONS After anesthesia induction, the patients received intravenously either 30 mg/kg of methylprednisolone (n = 15) or the same volume of saline as placebo (n = 14). MEASUREMENTS AND MAIN RESULTS Plasma interleukin-6, interleukin-8, interleukin-10 (biomarkers of inflammation), and 8-hydroxydeoxyguanosine concentrations (a biomarker of oxidative stress) were measured at the following 4 time points: preoperatively, during cardiopulmonary bypass, after protamine administration, and 6 hours postoperatively. The study parameters did not differ between the study groups preoperatively. Methylprednisolone reduced the proinflammatory cytokines interleukin-6 and interleukin-8 and increased the anti-inflammatory cytokine interleukin-10 postoperatively. Despite reduced inflammation, there were no differences in 8-hydroxydeoxyguanosine between the methylprednisolone and placebo groups. CONCLUSIONS The proinflammatory reaction and increase in free radical stress were not interrelated during congenital heart surgery in cyanotic infants with a univentricular heart defect undergoing the bidirectional Glenn procedure. High-dose methylprednisolone was ineffective in attenuating free radical stress.
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Affiliation(s)
- Juho Keski-Nisula
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Oiva Arvola
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sture Andersson
- Department of Neonatology, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eero Pesonen
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, Kirurginen sairaala, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Jahnukainen T, Keski-Nisula J, Tainio J, Valkonen H, Pätilä T, Jalanko H, Suominen P. Efficacy of corticosteroids in prevention of acute kidney injury in neonates undergoing cardiac surgery-A randomized controlled trial. Acta Anaesthesiol Scand 2018; 62:1072-1079. [PMID: 29667173 DOI: 10.1111/aas.13134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Heart surgery requiring cardiopulmonary bypass (CPB) causes an inflammatory response which may further induce acute kidney injury (AKI). In the present randomized controlled study we evaluated whether corticosteroids can prevent CPB related AKI in neonates undergoing heart surgery. METHODS Forty neonates were randomized to receive 2 mg/kg methylprednisolone followed by hydrocortisone infusion 0.2 mg/kg/h perioperatively with tapering doses for 5 days, or placebo administered in a similar fashion. The primary outcome was the inflammatory response (plasma concentrations of interleukins 6 and 10). The correspondence of the interleukin concentrations with AKI was analysed as secondary outcome. In addition, plasma and urine neutrophil gelatinase-associated lipocalin (NGAL), plasma cystatin C, and urine kidney injury molecule-1 (KIM-1) levels were measured. RESULTS Six patients (15%) developed post-operative AKI. No significant difference in the AKI occurrence between the treatment (n = 2) and the placebo (n = 4) groups could be found (risk ratio 2.00, 95% confidence interval 0.41-9.71; P = .661) despite significant reduction in inflammatory response in the treatment group. One patient in the treatment group and two patients in the placebo group required acute peritoneal dialysis. Plasma creatinine and cystatin C or urine NGAL and KIM-1 concentrations did not differ between the treatment and the placebo group. CONCLUSIONS Significantly reduced inflammatory reaction induced by corticosteroid treatment in neonates undergoing cardiac surgery did not reduce the incidence of AKI defined by KDIGO classification or decrease the rise of AKI biomarkers.
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Affiliation(s)
- T Jahnukainen
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Keski-Nisula
- Department of Anesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Tainio
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Valkonen
- Department of Anesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - T Pätilä
- Department of Pediatric Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Jalanko
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Suominen
- Department of Anesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Suominen PK, Keski-Nisula J, Ojala T, Rautiainen P, Jahnukainen T, Hästbacka J, Neuvonen PJ, Pitkänen O, Niemelä J, Kaskinen A, Salminen J, Lapatto R. Stress-Dose Corticosteroid Versus Placebo in Neonatal Cardiac Operations: A Randomized Controlled Trial. Ann Thorac Surg 2017; 104:1378-1385. [DOI: 10.1016/j.athoracsur.2017.01.111] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/26/2017] [Accepted: 01/30/2017] [Indexed: 01/20/2023]
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Pesonen E, Keski-Nisula J, Passov A, Vähätalo R, Puntila J, Andersson S, Suominen PK. Heart-Type Fatty Acid Binding Protein and High-Dose Methylprednisolone in Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1952-1956. [PMID: 29066147 DOI: 10.1053/j.jvca.2017.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Corticosteroids possess cardioprotection in experimental cardiac ischemia/reperfusion. The authors hypothesized that if cardioprotection of corticosteroids occured during pediatric cardiac surgery, then methylprednisolone used in cardiopulmonary bypass prime would reduce postoperative concentrations of heart-type fatty-acid-binding protein, a cardiac biomarker. DESIGN A double-blind, placebo-controlled, randomized clinical trial. SETTING Operating room and pediatric intensive care unit of a university hospital. PARTICIPANTS Forty-five infants and young children undergoing ventricular or atrioventricular septal defect correction. INTERVENTIONS The patients received one of the following: 30 mg/kg of methylprednisolone intravenously after anesthesia induction (n = 15), 30 mg/kg of methylprednisolone in cardiopulmonary bypass prime solution (n = 15), or placebo (n = 15). MEASUREMENTS AND MAIN RESULTS Plasma heart-type fatty-acid-binding protein (hFABP) was measured. Preoperatively, hFABP did not differ among the study groups. Methylprednisolone administered preoperatively and in the cardiopulmonary bypass prime solution reduced hFABP by 44% (p = 0.010) and 38% (p = 0.033) 6 hours postoperatively. hFABP significantly correlated with concomitant troponin T after protamine administration (R = 0.811, p < 0.001) and 6 hours postoperatively (R = 0.806, p < 0.001). CONCLUSIONS Methylprednisolone in cardiopulmonary bypass prime solution administered only a few minutes before cardiac ischemia confered cardioprotection of the same magnitude as preoperative methylprednisolone as indicated by hFABP concentrations. Rapid cardioprotective actions of corticosteroids in pediatric heart surgery observed previously experimentally may have occurred.
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Affiliation(s)
- Eero Pesonen
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Juho Keski-Nisula
- Department of Anaesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital; Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Arie Passov
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Raisa Vähätalo
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Anaesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital
| | - Juha Puntila
- Department of Paediatric Cardiac and Transplantation Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sture Andersson
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pertti K Suominen
- Department of Anaesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital; Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Pesonen E, Keski-Nisula J, Andersson S, Palo R, Salminen J, Suominen PK. High-dose methylprednisolone and endothelial glycocalyx in paediatric heart surgery. Acta Anaesthesiol Scand 2016; 60:1386-1394. [PMID: 27604388 DOI: 10.1111/aas.12785] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Corticosteroids are used in paediatric heart surgery to attenuate systemic inflammatory response. Glycocalyx regulates vascular permeability, shear stress and cell adhesion on the endothelium. Syndecan-1 serves as a biomarker of glycocalyx degradation. Hydrocortisone decreased endothelial glycocalyx degradation in an experimental model. Our hypothesis was that high-dose methylprednisolone decreases glycocalyx degradation as measured by plasma sydecan-1 concentration in children undergoing cardiac surgery. METHODS Two double-blinded, randomized, placebo-controlled trials were conducted. In the first trial ('neonatal trial'), 40 neonates undergoing open heart surgery received either 30 mg/kg intravenous methylprednisolone (n = 20) or placebo (n = 20). In the second trial ('VSD trial'), 45 infants and very young children, undergoing ventricular or atrioventricular septal defect correction received one of the following: 30 mg/kg of methylprednisolone intravenously after anaesthesia induction (n = 15), 30 mg/kg methylprednisolone in the cardiopulmonary bypass prime solution (n = 15) or placebo (n = 15). Plasma syndecan-1 concentrations were measured. Results were expressed both as absolute concentrations and in relative concentrations as multiples of the baseline values of syndecan-1. RESULTS There were no statistically significant differences between the neonate trial groups for absolute syndecan-1 concentrations. However, operative administration of methylprednisolone to neonates significantly reduced the relative increases of syndecan-1 at weaning from cardiopulmonary bypass (P = 0.008) and at 6 h post-operatively (P = 0.018). There were no statistically significant differences in absolute or relative increases of syndecan-1 between the VSD trial study groups. CONCLUSION High-dose methylprednisolone reduces shedding of glycocalyx in neonates after complex cardiac surgery but not in older infants after repair of VSD/AVSD with shorter ischaemia times.
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Affiliation(s)
- E. Pesonen
- Division of Anaesthesiology, Peijas Hospital, Department of Anaesthesiology; Intensive Care and Pain Medicine; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - J. Keski-Nisula
- Division of Anaesthesiology; Children's Hospital; Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - S. Andersson
- Children's Hospital; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - R. Palo
- Division of Anaesthesiology; Children's Hospital; Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - J. Salminen
- Department of Paediatric Surgery; Children's Hospital; Helsinki University Hospital and University of Helsinki; Helsinki Finland
| | - P. K. Suominen
- Division of Anaesthesiology; Children's Hospital; Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital; Helsinki Finland
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Keski-Nisula J, Pesonen E, Olkkola KT, Ahlroth T, Puntila J, Andersson S, Neuvonen PJ, Suominen PK. High-Dose Methylprednisolone Has No Benefit Over Moderate Dose for the Correction of Tetralogy of Fallot. Ann Thorac Surg 2016; 102:870-876. [DOI: 10.1016/j.athoracsur.2016.02.089] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
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Keski-Nisula J, Suominen PK, Olkkola KT, Peltola K, Neuvonen PJ, Tynkkynen P, Salminen JT, Andersson S, Pesonen E. Effect of Timing and Route of Methylprednisolone Administration During Pediatric Cardiac Surgical Procedures. Ann Thorac Surg 2015; 99:180-5. [DOI: 10.1016/j.athoracsur.2014.08.042] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 08/20/2014] [Accepted: 08/29/2014] [Indexed: 01/09/2023]
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Keski-Nisula J, Pesonen E, Olkkola KT, Peltola K, Neuvonen PJ, Tuominen N, Sairanen H, Andersson S, Suominen PK. Methylprednisolone in Neonatal Cardiac Surgery: Reduced Inflammation Without Improved Clinical Outcome. Ann Thorac Surg 2013; 95:2126-32. [DOI: 10.1016/j.athoracsur.2013.02.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 01/31/2013] [Accepted: 02/06/2013] [Indexed: 11/30/2022]
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Suominen PK, Keski-Nisula J, Tynkkynen P, Kantoluoto S, Olkkola KT, Mildh L. The effect of tepid amino acid-enriched induction cardioplegia on the outcome of infants undergoing cardiac surgery. Perfusion 2012; 27:338-44. [DOI: 10.1177/0267659112442237] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Despite promising experimental results, no information has been published on the clinical effects of amino acid-enriched induction cardioplegic solution on outcome in children undergoing cardiac surgery. Methods: This is a retrospective study of 185 consecutive patients younger than 12 months with one of the following defects undergoing open heart surgery: atrioventricular septal defect, transposition of the great arteries, tetralogy of Fallot or ventricular septal defect. Patients were divided into two groups according to the following myocardial protection approaches: tepid substrate-enriched induction cardioplegia followed by cold blood cardioplegia (n=113) or only cold blood induction cardioplegia (n=72). Patient allocation was determined by the anesthesiologist in charge of cardiopulmonary bypass (CPB). The primary outcome measure was postoperative myocardial injury assessed by troponin T level and inotrope score. Results: Demographic data were similar for both groups. Cardioplegic induction had no overall effect for inotrope score (16.3 ± 9.2 vs.17.9 ± 10.0, p=0.276) or lactate release (1.8 ± 1.3 vs. 1.6 ± 0.8, p=0.110) on arrival to the paediatric intensive care unit. On the first postoperative day, there were no significant differences between the cardioplegia groups for inotrope score (13.7 ± 8.7 vs.14.3 ± 9.1, p=0.657), troponin T (2.4 ± 1.6 vs. 2.8 ± 2.7 μg/L, p=0.267), lactate (1.5 ± 2.0 vs. 1.5 ± 0.8, p=0.972), or any of the other clinical outcome measures. Conclusions: Compared to cold cardioplegia alone, the administration of tepid induction cardioplegia had no effect on the clinical outcome of infants who underwent cardiac surgery.
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Affiliation(s)
- PK Suominen
- Department of Anesthesia and Intensive Care, Children’s Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - J Keski-Nisula
- Department of Anesthesia and Intensive Care, Children’s Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - P Tynkkynen
- Department of Anesthesia and Intensive Care, Children’s Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - S Kantoluoto
- Department of Anesthesia and Intensive Care, Children’s Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - KT Olkkola
- Department of Anesthesiology, Intensive Care, Emergency Care and Pain Medicine, University of Turku and Turku University Hospital, Finland
| | - L Mildh
- Department of Anesthesia and Intensive Care, Meilahti Hospital, Helsinki University Central Hospital, Finland
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Pietilä J, Mäkinen P, Pajari T, Suominen S, Keski-Nisula J, Sipilä K, Huhtala A, Uusitalo H. Eight-year Follow-up of Photorefractive Keratectomy for Myopia. J Refract Surg 2004; 20:110-5. [PMID: 15072308 DOI: 10.3928/1081-597x-20040301-03] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE We evaluated 8-year results of excimer laser photorefractive keratectomy (PRK) for myopia in terms of stability and late complications. METHODS Ninety-two myopic eyes of 55 patients were treated with a single-step method using an Aesculap-Meditec MEL 60 excimer laser with a 5.0-mm ablation zone. Treated eyes were divided into three groups according to preoperative refraction: low myopes (< or = -6.00 D), medium myopes (-6.10 to -10.00 D), and high myopes (>-10.00 D). RESULTS Change in myopic regression stabilized in all myopia groups within 12 months, although a small myopic shift occurred up to 8 years after PRK. Mean change in refraction between 2 and 8 years was -0.42 +/- 0.48 D for low myopes, -0.37 +/- 0.34 D for medium myopes, and -0.41 +/- 0.50 D for high myopes. The percentage of eyes within +/- 1.00 D of emmetropia 8 years after PRK was 78.3% in the low myopia group, 68.8% in the medium myopia group, and 57.1% in the high myopia group. One eye lost 2 lines of best spectacle-corrected visual acuity due to irregular astigmatism. In 13.0% of eyes, a residual trace corneal haze was observed, which had no effect on visual acuity. Apart from the loss of 2 lines of BSCVA in one eye, there were no other late complications during the study period. CONCLUSIONS The mean change in refraction between 2 and 8 years was less than -0.50 D, regardless of preoperative refraction, and may be attributed to natural age-related refractive change. The appearance of residual corneal haze after 8 years correlated with the amount of myopic correction. PRK was a safe and stable surgical procedure in this group of patients.
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Affiliation(s)
- Juhani Pietilä
- Kirurgipalvelu, Hämeenkatu 15 B 4, FIN-33100 Tampere, Finland.
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