ABSTRACT
Little is known about which paediatric patients respond to hydrocortisone rescue therapy (HRT) with improvement of haemodynamic stability in refractory hypotension after cardiopulmonal bypass. Data were gathered retrospectively from children who received HRT in refractory hypotension after cardiopulmonary bypass in the period from 2000 to 2010. One hundred and sixty-six out of 1,273 children, 150 <1 year and 16 >1 year were enrolled. HRT improved haemodynamics significantly, increased blood pressure, decreased the vasoactive-inotropic score and plasma lactate concentrations in all children >1 year and in 82 % (123 out of 150) of the infants <1 year. Non-responders <1 year were significantly younger, lighter, mostly male infants and had longer cardiopulmonary bypass support time. Serum lactate and paediatric risk of mortality score were significantly higher in non-responders at time of initiation of HRT. Mortality was significantly higher in non-responders versus responders (2.44 vs. 13.5 %; p = 0.0008). HRT caused no adverse effects like electrolyte disturbances or hyperglycaemia. HRT in refractory hypotension after paediatric cardiac surgery is safe but not all infants <1 year show haemodynamic response to HRT. Non-response to HRT is associated with significantly higher mortality.
Subject(s)
Cardiac Surgical Procedures/adverse effects , Cardiopulmonary Bypass/adverse effects , Hemodynamics , Hydrocortisone/adverse effects , Hydrocortisone/therapeutic use , Hypotension/drug therapy , Adolescent , Age Factors , Cardiac Surgical Procedures/mortality , Cardiopulmonary Bypass/mortality , Child , Child, Preschool , Female , Humans , Hydrocortisone/administration & dosage , Hyperglycemia/chemically induced , Hypotension/etiology , Hypotension/physiopathology , Infant , Lactic Acid/blood , Male , Retrospective Studies , Risk Factors , Steroids/adverse effects , Steroids/therapeutic use , Time Factors , Treatment Outcome , Water-Electrolyte Balance/drug effectsABSTRACT
HISTORY: A 40-year-old woman and a 50-year-old man were admitted with acute chest pain indicative of an acute coronary syndrome. INVESTIGATIONS: In addition to ECG changes suggestive of acute ischemia and a minor increase in the serum concentration of troponin-I both patients had a severely reduced left ventricular function with extensive apical akinesis on echocardiography (LV- ejection fraction 20, respectively 40%). Stenotic coronary artery disease was excluded by coronary angiography, however left ventriculography showed a "ballooned" apex resembling an aneurysm. DIAGNOSIS, TREATMENT AND COURSE: Both patients were observed and treated symptomatically in the intensive care unit. Within four weeks the LV-function had completely recovered in both patients. Both patients had an atypical acute coronary syndrome as indicated by electrocardiographic signs of ischemia and serological markers. After perusal of the relevant literature the diagnosis of "apical ballooning" based on the finding of a "ballooned" akinesis of the left ventricular apex in the absence of coronary artery stenosis or a reasonable alternative cause of myocardial ischemia was made. The aneurysm-like left ventricular dysfunction is fully reversible without specific treatment. CONCLUSION: Left apical ballooning is a rare, but increasingly recognized diagnosis in patients presenting with the clinical picture of cardiac ischemia in the absence of coronary artery disease. The pathogenesis of the LV-dysfunction, which is reversible, is not known and the prognosis is good in patients who survive the initial period of severe ventricular dysfunction.
