Postoperative Pulmonary Hemodynamics and Systemic Inflammatory Response in Pediatric Patients Undergoing Surgery for Congenital Heart Defects.

There is scarce information about the relationships between postoperative pulmonary hemodynamics, inflammation, and outcomes in pediatric patients with congenital cardiac communications undergoing surgery. We prospectively studied 40 patients aged 11 (8-17) months (median with interquartile range) with a preoperative mean pulmonary arterial pressure of 48 (34-54) mmHg who were considered to be at risk for postoperative pulmonary hypertension. The immediate postoperative pulmonary/systemic mean arterial pressure ratio (PAP/SAPIPO, mean of first 4 values obtained in the intensive care unit, readings at 2-hour intervals) was correlated directly with PAP/SAP registered in the surgical room just after cardiopulmonary bypass (r = 0.68, p < 0.001). For the entire cohort, circulating levels of 15 inflammatory markers changed after surgery. Compared with patients with PAP/SAPIPO ≤ 0.40 (n = 22), those above this level (n = 18) had increased pre- and postoperative serum levels of granulocyte colony-stimulating factor (p = 0.040), interleukin-1 receptor antagonist (p = 0.020), interleukin-6 (p = 0.003), and interleukin-21 (p = 0.047) (panel for 36 human cytokines) and increased mean platelet volume (p = 0.018). Using logistic regression analysis, a PAP/SAPIPO > 0.40 and a heightened immediate postoperative serum level of macrophage migration inhibitory factor (quartile analysis) were shown to be predictive of significant postoperative cardiopulmonary events (respective hazard ratios with 95% CIs, 5.07 (1.10-23.45), and 3.29 (1.38-7.88)). Thus, the early postoperative behavior of the pulmonary circulation and systemic inflammatory response are closely related and can be used to predict outcomes in this population.

Macrophage migration inhibitory factor and chemokine RANTES in young pediatric patients with congenital cardiac communications: Relation to hemodynamic parameters and the presence of Down syndrome.

Inflammation and immunity are central in the pathobiology of pulmonary vascular disorders. Preliminary headway has been made in understanding the relationships between inflammatory proteins and clinical parameters in pediatric congenital heart disease. In this study, we analyzed serum levels of macrophage migration inhibitory factor (MIF) and regulated on activation normal T cell expressed and secreted chemokine (RANTES) in 87 patients with unrestrictive congenital cardiac communications and signs of pulmonary hypertension (age 2-36 months) and 50 pediatric controls. They were investigated in relation to clinical and hemodynamic parameters and the presence of Down syndrome. Hemodynamics was assessed by transthoracic Doppler echocardiography and cardiac catheterization. Chemokines were analyzed in serum using a chemiluminescence assay. The highest MIF levels were observed in very young subjects with heightened pulmonary vascular resistance but who presented a positive response to vasodilator challenge with inhaled nitric oxide. In contrast, RANTES levels were higher in patients with pulmonary overcirculation and congestion, correlating nonlinearly with pulmonary blood flow. Levels of both chemokines were higher in subjects with Down syndrome than in nonsyndromic individuals, but the difference was observed only in patients, not in the control group. In patients with Down syndrome, there was a direct relationship between preoperative serum MIF and the level of pulmonary artery pressure observed 6 months after surgical repair of cardiac anomalies. Thus, it was interesting to observe that MIF, which is key in the innate immune response and chemokine RANTES, which is highly expressed in respiratory viral infections were related to clinical and hemodynamic abnormalities associated with pediatric congenital heart disease.

Down syndrome and postoperative hemodynamics in patients undergoing surgery for congenital cardiac communications.

Although Down syndrome (DS) is considered a risk factor for hemodynamic instabilities (mainly pulmonary hypertension-PH) following surgery for congenital cardiac communications, many DS patients do surprising well postoperatively. We prospectively analyzed perioperative factors for a possible correlation with post-cardiopulmonary bypass (CPB) inflammatory reaction and postoperative PH in pediatric subjects. Sixty patients were enrolled (age 3 to 35 months), 39 of them with DS. Clinical and echocardiographic parameters (anatomical and hemodynamic) were computed preoperatively. Pulmonary and systemic mean arterial pressures (PAP and SAP) were assessed invasively intra and postoperatively. Immediate postoperative PAP/SAP ratio (PAP/SAPIPO) and the behavior of pressure curves were selected as primary outcome. Serum levels of 36 inflammatory proteins were measured by chemiluminescence preoperatively and 4 h post CPB. Of all factors analyzed, peripheral oxygen saturation (O2Sat, bedside assessment) was the only preoperative predictor of PAP/SAPIPO at multivariate analysis (p = 0.007). Respective values in non-DS, DS/O2Sat ≥ 95% and DS/O2Sat < 95% subgroups were 0.34 (0.017), 0.40 (0.027) and 0.45 (0.026), mean (SE), p = 0.004. The difference between non-DS and DS groups regarding postoperative PAP curves (upward shift in DS patients, p = 0.015) became nonsignificant (p = 0.114) after adjustment for preoperative O2Sat. Post-CPB levels of at least 5 cytokines were higher in patients with O2Sat < 95% versus those at or above this level, even within the DS group (p < 0.05). Thus, a baseline O2Sat < 95% representing pathophysiological phenomena in the airways and the distal lung, rather than DS in a broad sense, seems to be associated with post-CPB inflammation and postoperative PH in these patients.

Respiratory viruses and postoperative hemodynamics in patients with unrestrictive congenital cardiac communications: a prospective cohort study.

BACKGROUND: Pulmonary vascular abnormalities pose a risk for severe life-threatening hemodynamic disturbances following surgical repair of congenital cardiac communications (CCCs). In the distal lung, small airways and vessels share a common microenvironment, where biological crosstalks take place. Because respiratory cells infected by viruses express a number of molecules with potential impact on airway and vascular remodeling, we decided to test the hypothesis that CCC patients carrying viral genomes in the airways might be at a higher risk for pulmonary (and systemic) hemodynamic disturbances postoperatively. METHODS: Sixty patients were prospectively enrolled (age 11 [7-16] months, median with interquartile range). Preoperative pulmonary/systemic mean arterial pressure ratio (PAP/SAP) was 0.78 (0.63-0.88). The presence or absence of genetic material for respiratory viruses in nasopharyngeal and tracheal aspirates was investigated preoperatively in the absence of respiratory symptoms using real-time polymerase chain reaction (kit for detection of 19 pathogens). Post-cardiopulmonary bypass (CPB) inflammatory reaction was analyzed by measuring serum levels of 36 inflammatory proteins (immunoblotting) 4 h after its termination. Postoperative hemodynamics was assessed using continuous recording of PAP and SAP with calculation of PAP/SAP ratio. RESULTS: Viral genomes were detected in nasopharynx and the trachea in 64% and 38% of patients, respectively. Rhinovirus was the most prevalent agent. The presence of viral genomes in the trachea was associated with an upward shift of postoperative PAP curve (p = 0.011) with a PAP/SAP of 0.44 (0.36-0.50) in patients who were positive versus 0.34 (0.30-0.45) in those who were negative (p = 0.008). The presence or absence of viral genomes in nasopharynx did not help predict postoperative hemodynamics. Postoperative PAP/SAP was positively correlated with post-CPB levels of interleukin-1 receptor antagonist (p = 0.026), macrophage migration inhibitory factor (p = 0.019) and monocyte chemoattractant protein-1 (p = 0.031), particularly in patients with virus-positive tracheal aspirates. CONCLUSIONS: Patients with CCCs carrying respiratory viral genomes in lower airways are at a higher risk for postoperative pulmonary hypertension, thus deserving special attention and care. Preoperative exposure to respiratory viruses and post-CPB inflammatory reaction seem to play a combined role in determining the postoperative behavior of the pulmonary circulation.

Significados, avaliação e perspectivas da sistematização da assistência de enfermagern (SAE) em um hospital cardiológico / Nursing process at a cardiologic institution: meanings, evaluation and perspectives / Significados, evaluación y perspectivas de la sistematización de la assistência de enfermeira (SAE) em um hospital cardiológico

SAE e uma ferramenta de gestão da qualidade assistencial do enfermeiro, sendo essencial mantê-la aplicável, atualizada e em continua avaliação. Este estudo descritivo e exploratório foi realizado em hospital público de referência em cardiologia e objetivou identificar o significado, a importância, a aplicabilidade e a validade da SAE, implantada sob o ponto de vista dos enfermeiros, utilizando-se formulário adaptado da técnica de Delphis com 66 desses profissionais. As significados atribuídos à SAE foram utilizados como ferramenta para gestão do cuidado ao ao paciente e para valorização do enfermeiro. Esses profissionais concordaram com relação a avaliação de importância, a aplicabilidade e a validade, mas constatou-se a necessidade de revisão do histórico e do diagnóstico de enfermaqem. Sugestões apontadas por eles foram para tornar o processo e suas fases mais objetivos, atualizados e específicos às unidades, bem como investir no aprimoramentoe no dimensionamento de pessoal,gerando subsídios para planejamento da continuidade do trabalho ao grupo de SAE.

The nursing assistance systematization (SAE) is an administration tool for quality nursing assistance. It is essential to maintain the process as much applicable and updated as possible, as well as in continuous evaluation. This descriptive, exploratory study was carried out at a public hospital, a referral center for cardiology, and aimed to identify the meaning, the importance, the applicability, and the validity of the SAE under the nurses' point of view.We have used an adapted form from the Delphis technique in a sample of 66 nurses. The meanings attributed to SAE involved a tool for the administration of the patient's care and nursing valorization.There was agreement among the nurses in regard of the evaluation of the importance, the applicability and the validity of the SAE, but aneed for a revision of the patient's nursing history and nursing diagnosis was identified.The nurses' suggestions involved turning the process and the steps as much objective, updated, and specific to the units as possible, andto invest in their professional improvement and allocation of human resources. This may offer information for the continuity of the work of the SAE group.

La SAE es una herramienta de gestión de la calidad asistencial del enfermero, y es esencial manteneria aplicable, actualizada y en continua evatuación. Este estudio, descriptivo y exploratorio fue realizado en un hospital público de referencia en cardiologla, y su objetivo fue identificar el significado, jmportancla, aplicabilidad y validez de la SAE implantada desde el punta de vista de los enfermeros, utilizando un formulario adaptado de la técnica de Delphis, junto a una muestra de 66 enfermeros. Los significados atribuidos a la SAE fueron considerados una herramienta para la gestión del cuidado al paciente y de valorización del enfermero. Se observe también la concordância de los enfermeros con relacion a la evaluacion de importancia, aplicabilidady validez; sin embargo, se constato la necesidad de una revision del Histórico y Diaqnóstico de Enfermería. Los enfermeiros sugirieron que esta herramienta debería volver el proceso y sus fases mas objetivas, actualizadas, específicas a las unidades, así como también deberían invertir en er perfeccionamiento y valoración del personal, de manera que genere subsídios para la planificación de la continuidad del trabajo para el grupo de SAE.