Indicadores pronósticos clínicos en el posoperatorio de cirugía cardiovascular pediátrica y su relación con la cinética del estrés oxidativo / Prognostic indicators after cardiac surgery in children and their relationship with the oxidative stress response

Objetivos. Analizar la evolución de parámetros de estrés oxidativo en el posoperatorio de cirugía cardiovascular pediátrica y correlacionarlos con diferentes indicadores clínicos pronósticos. Material y métodos. Treinta niños, de entre un mes y 14 años, peso > 5 kg, sometidos a circulación extracorpórea. Se obtuvieron muestras preoperatoria, posoperatoria inmediata y tras 18-20 h. Se analizó la capacidad de peroxidación lipídica de las membranas celulares mediante la cuantificación de productos de reacción con el ácido tiobarbitúrico, cuyo principal representante es el malondialdehído; se cuantificó el contenido celular de glutatión total, oxidado y reducido (representantes de la respuesta antioxidante). Se analizaron las variables clínicas que permitieran establecer una puntuación para el síndrome de respuesta inflamatoria sistémica asociado a circulación extracorpórea. Resultados. Treinta pacientes con una mediana de edad de 4,1 años (rango intercuartílico [RIC]: 2,7; 8,0); el 62,1% eran niñas; mediana de desviaciones estándar de peso −0,39 (RIC: −0,76; 0,24), de talla −0,22 (RIC: −0,74; 0,27) y de IMC −0,43 (RIC: −1; 0,45). Mediana de tiempo quirúrgico 79 min (RIC: 52,5; 125,5), mediana de pinzamiento 38,5 min (RIC: 22; 59). Aumentó el malondialdehído y disminuyó el glutatión en ambos momentos posoperatorios, con clara correlación directa, estadísticamente significativa, del tiempo de circulación extracorpórea con el porcentaje de descenso de glutatión total entre preoperatorio y posoperatorio inmediato y entre el preoperatorio y el posoperatorio tardío. Hubo una correlación estadística entre los niveles de glutatión total tras 18-20 h posoperatorias y el tiempo de duración de la ventilación mecánica y la pertenencia al grupo de síndrome de respuesta inflamatoria sistémica. Conclusiones. La circulación extracorpórea activa mediadores inflamatorios, máximo tras el pinzamiento aórtico, mejorando tras 24 h, siendo dependiente de los tiempos quirúrgicos. El desarrollo de respuesta inflamatoria está asociado a una mayor duración de la ventilación mecánica, una estancia más prolongada en Cuidados Intensivos, puntuaciones mayores del Modelo de Aristóteles y tiempos más largos quirúrgicos. Los que no cumplen criterios de respuesta inflamatoria tienen más niveles de glutatión en el posoperatorio tardío (AU)

Objectives. To analyse the trend in lipid peroxidation and antioxidant response as key markers of oxidative stress after paediatric cardiovascular surgery, and compare them with other internationally accepted clinical prognostic indicators. Patients and methods. A prospective study was conducted on 30 children aged one month to 14 years, weight > 5 kg, undergoing cardiopulmonary bypass surgery. Blood samples were taken just before the intervention, immediately after surgery, and after 18-20 h. Cell membrane lipid peroxidation was analysed by quantifying malondialdehyde, as well as measuring total glutathione (oxidized and reduced), as representatives of antioxidant response. An analysis was also performed on clinical variables for establishing a score for the systemic inflammatory response syndrome associated with cardiopulmonary bypass. Results. The study included 30 children with a mean age of 4.1 years old (interquartile range [IQR]: 2.7; 8.0). Of these, 62.1% were girls. The standard deviation of the median weight was −0.39 (IQR: −0.76; 0.24), the median height was −0.22 (IQR: −0.74; 0.27), and the median BMI was −0.43 (IQR: −1; 0.45). The final surgery times were divided into 2 parts: total time of extracorporeal circulation, with a mean of 79 min (IQR: 52.5; 125.5), and the clamping time, a measurement included in the previous figure with a mean value of 38.5 min (IQR: 22; 59). Malondialdehyde increased and glutathione decreased in postoperative time, with clear, statistically significant direct correlation between time of extracorporeal circulation and percentage decrease in total glutathione between preoperative and immediate postoperative time, and a decline between the preoperative and late postoperative. There was a statistical correlation between total glutathione levels at 18-20 h postoperatively and the duration of mechanical ventilation and inflammatory systemic response syndrome. Conclusions. Surgery with extracorporeal circulation performed in children activates inflammatory mediators, being maximum after aortic clamping, and improving after the first 24 h. The level of oxidative stress activation depends on surgical times. The development of systemic inflammatory response syndrome is associated with longer duration of mechanical ventilation, longer stay in intensive care, higher scores in the Aristotle model and longer surgical times. Those who do not meet criteria for inflammatory response have higher levels of glutathione in first 24 h (AU)

Prognostic indicators after cardiac surgery in children and their relationship with the oxidative stress response.

OBJECTIVES: To analyse the trend in lipid peroxidation and antioxidant response as key markers of oxidative stress after paediatric cardiovascular surgery, and compare them with other internationally accepted clinical prognostic indicators. PATIENTS AND METHODS: A prospective study was conducted on 30 children aged one month to 14 years, weight>5 kg, undergoing cardiopulmonary bypass surgery. Blood samples were taken just before the intervention, immediately after surgery, and after 18-20 h. Cell membrane lipid peroxidation was analysed by quantifying malondialdehyde, as well as measuring total glutathione (oxidized and reduced), as representatives of antioxidant response. An analysis was also performed on clinical variables for establishing a score for the systemic inflammatory response syndrome associated with cardiopulmonary bypass. RESULTS: The study included 30 children with a mean age of 4.1 years old (interquartile range [IQR]: 2.7; 8.0). Of these, 62.1% were girls. The standard deviation of the median weight was -0.39 (IQR: -0.76; 0.24), the median height was -0.22 (IQR: -0.74; 0.27), and the median BMI was -0.43 (IQR: -1; 0.45). The final surgery times were divided into 2 parts: total time of extracorporeal circulation, with a mean of 79 min (IQR: 52.5; 125.5), and the clamping time, a measurement included in the previous figure with a mean value of 38.5 min (IQR: 22; 59). Malondialdehyde increased and glutathione decreased in postoperative time, with clear, statistically significant direct correlation between time of extracorporeal circulation and percentage decrease in total glutathione between preoperative and immediate postoperative time, and a decline between the preoperative and late postoperative. There was a statistical correlation between total glutathione levels at 18-20 h postoperatively and the duration of mechanical ventilation and inflammatory systemic response syndrome. CONCLUSIONS: Surgery with extracorporeal circulation performed in children activates inflammatory mediators, being maximum after aortic clamping, and improving after the first 24h. The level of oxidative stress activation depends on surgical times. The development of systemic inflammatory response syndrome is associated with longer duration of mechanical ventilation, longer stay in intensive care, higher scores in the Aristotle model and longer surgical times. Those who do not meet criteria for inflammatory response have higher levels of glutathione in first 24h.

Perspectiva actual de la cirugía de las cardiopatías congénitas / Current perspective of congenital heart disease surgery

La cirugía cardiovascular pediátrica ha experimentado avances significativos en los últimos años, beneficiándose de los avances tecnológicos conseguidos no solo en la especialidad de la Cirugía Cardiovascular, sino también de los avances y la implicación de profesionales de Anestesia, Cuidados Intensivos, Neonatología y especialmente la Cardiología Pediátrica. Es muy amplio el espectro de pacientes que son intervenidos en nuestro ámbito asistencial: desde el neonato nacido pretérmino a las 24-25 semanas de gestación con ductus arterioso persistente hasta el adolescente o adulto joven con cardiopatía congénita que pudo ser o no intervenido durante su infancia y ha sido seguido evolutivamente hasta llegar a esa edad. Las intervenciones se centran preferentemente cada vez más en los grupos extremos de edad, con tendencia clara hacia la cirugía precoz y correctora en el primer año de vida. Por tanto una buena parte de los procedimientos son en la actualidad realizados en lactantes y neonatos. La progresiva mejora de resultados en los últimos años y la transparencia en el conocimiento y utilización de los mismos hace que en la actualidad el listón esté muy alto en cuanto a la exigencia en la mejora continua y la evaluación periódica de las distintas unidades. En este artículo describimos los avances más importantes que se han producido en los últimos años en el campo de la cirugía de las cardiopatías congénitas así como una breve mención de la actividad realizada en nuestro centro (AU)

Paediatric cardiac surgery has undergone significant improvements over the last years, due to the technological advances made in this area, as well as advances and implication of other disciplines, mainly Anesthesia, Intensive Care, Neonatology and especially Pediatric cardiology. There is a wide range of patients that are operated, from the premature baby with patent ductus arteriosus born at 24-25 weeks of gestation, to the grown-up congenital heart disease patient. Operations currently performed are focused on the end groups of age. There is a very clear tendency towards early corrective surgery; therefore most of interventions are done preferentially in neonates and infants. The btter outcomes that have been produced over the last years and the transparency of results have made most surgical groups take action towards continuous medical improvements and periodical evaluation of the different units. In this article the most important advances in the field of congenital heart surgery are described and a brief summary from our results is given (AU)

Use of the Batista procedure to discontinue bypass following aortic reimplantation of an anomalous left coronary artery.

A four-month-old infant with anomalous origin of the left coronary artery from the pulmonary artery developed severe left ventricular failure after aortic reimplantation, despite prolonged supportive cardiopulmonary bypass with high level inotropic support and several abortive attempts for discontinuation. The Batista procedure was performed and the patient was successfully weaned from bypass. Postoperative recovery was uneventful, and at one-year follow-up she remains asymptomatic.