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1.
Anesth Analg ; 2020 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-32149756

RESUMO

BACKGROUND: Although immunomodulatory effects of anesthetics have been increasingly recognized, their underlying molecular mechanisms are not completely understood. Toll-like receptors (TLRs) are one of the major receptors to recognize invading pathogens and danger signals from damaged host tissues to initiate immune responses. Among the TLR family, TLR2 and TLR4 recognize a wide range of ligands and are considered to be important players in perioperative pathophysiology. Based on our recent finding that volatile anesthetics modulate TLR4 function, we tested our hypothesis that they would also modulate TLR2 function. METHODS: The effect of anesthetics isoflurane, sevoflurane, propofol, and dexmedetomidine on TLR2 activation was examined by reporter assays. An anesthetic that affected the activation was subjected to in silico rigid docking simulation on TLR2. To test our prediction that sevoflurane and a TLR1/TLR2 ligand Pam3CSK4 would compete for the same pocket of TLR2, we performed Pam3CSK4 competitive binding assay to TLR2 using HEK cells stably transfected with TLR2 (HEK-TLR2) with or without sevoflurane. We examined the effect of different anesthetics on the functions of human neutrophils stimulated with TLR2 ligands. Kruskal-Wallis test and Mann-Whitney U test were used for statistical analysis. RESULTS: We observed that the attenuation of TLR1/TLR2 activation was seen on sevoflurane exposure but not on isoflurane, propofol, or dexmedetomidine exposure. The attenuation of TLR2/TLR6 activation was not seen in any of the anesthetics tested. The rigid docking simulation predicted that sevoflurane and Pam3CSK4 bound to the same pocket of TLR1/TLR2 complex. The binding of Pam3CSK4 to HEK-TLR2 cells was impaired in the presence of sevoflurane, indicating that sevoflurane and Pam3CSK4 competed for the pocket, as predicted in silico. The stimulation of neutrophils with Pam3CSK4 induced L-selection shedding but did not affect phagocytosis and reactive oxygen species production. L-selectin shedding from neutrophils was attenuated only by sevoflurane, consistent with the result of our reporter assays. CONCLUSIONS: We found that TLR1/TLR2 activation was attenuated by sevoflurane, but we found no evidence for attenuation by isoflurane, propofol, or dexmedetomidine at clinically relevant concentrations. Our structural analysis and competition assay supported that sevoflurane directly bound to TLR2 at the interphase of the TLR1/TLR2 complex. Sevoflurane attenuated neutrophil L-selectin shedding, an important step for neutrophil migration.

2.
PLoS One ; 14(5): e0216163, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31071106

RESUMO

BACKGROUND: Perioperative infections, particularly surgical site infections pose significant morbidity and mortality. Phagocytosis is a critical step for microbial eradication. We examined the effect of commonly used anesthetics on macrophage phagocytosis and its mechanism. METHODS: The effect of anesthetics (isoflurane, sevoflurane, propofol) on macrophage phagocytosis was tested using RAW264.7 mouse cells, mouse peritoneal macrophages, and THP-1 human cells. Either opsonized sheep erythrocytes or fluorescent labeled Escherichia coli were used as phagocytic objects. The activation of Rap1, a critical protein in phagocytosis was assessed using the active Rap1 pull-down and detection kit. To examine anesthetic binding site(s) on Rap1, photolabeling experiments were performed using azi-isoflurane and azi-sevoflurane. The alanine scanning mutagenesis of Rap1 was performed to assess the role of anesthetic binding site in Rap1 activation and phagocytosis. RESULTS: Macrophage phagocytosis was significantly attenuated by the exposure of isoflurane (50% reduction by 1% isoflurane) and sevoflurane (50% reduction by 1.5% sevoflurane), but not by propofol. Photolabeling experiments showed that sevoflurane directly bound to Rap1. Mutagenesis analysis demonstrated that the sevoflurane binding site affected Rap1 activation and macrophage phagocytosis. CONCLUSIONS: We showed that isoflurane and sevoflurane attenuated macrophage phagocytosis, but propofol did not. Our study showed for the first time that sevoflurane served as a novel small GTPase Rap1 inhibitor. The finding will further enrich our understanding of yet-to-be determined mechanism of volatile anesthetics and their off-target effects. The sevoflurane binding site was located outside the known Rap1 functional sites, indicating the discovery of a new functional site on Rap1 and this site would serve as a pocket for the development of novel Rap1 inhibitors.


Assuntos
Anestésicos Inalatórios/farmacologia , Macrófagos/efeitos dos fármacos , Fagocitose/efeitos dos fármacos , Animais , Linhagem Celular , Humanos , Isoflurano/farmacologia , Camundongos , Propofol/farmacologia , Células RAW 264.7 , Sevoflurano/farmacologia , Ovinos
3.
Anesth Analg ; 129(1): 27-40, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30451723

RESUMO

Pulmonary vein stenosis (PVS) is a rare disorder that leads to progressive narrowing of the extrapulmonary veins. PVS has been reported in both children and adults and in its worse iteration leads to pulmonary hypertension, right ventricular failure, and death. Multiple etiologies of PVS have been described in children and adults. This review will focus on intraluminal PVS in children. Intraluminal PVS has an estimated incidence ranging from 0.0017% to 0.03%. It is associated with conditions such as prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis, Smith-Lemli-Opitz syndrome, and Down syndrome. Cardiac catheterization and pulmonary vein angiography are the gold standard for diagnosis and anatomic delineation. Other imaging modalities including magnetic resonance imaging, chest tomography, and transesophageal echocardiography are increasingly being used. Mortality of PVS in children is approximately 50%. Predictors of mortality include involvement of ≥3 pulmonary veins, bilateral pulmonary vein involvement, onset of PVS in infancy, elevated pulmonary artery pressure or systolic pulmonary artery-to-aortic pressure ratio, right ventricular dysfunction, restenosis after surgery, distal/upstream disease, and disease progression to previously uninvolved pulmonary veins. Treatment includes catheter-based pulmonary vein dilations with or without stenting, surgical interventions, medical therapy, and in some instances, lung transplantation. Cardiac catheterization for PVS involves a comprehensive hemodynamic and anatomic assessment of the pulmonary veins as well as therapeutic transcatheter interventions. Several surgical strategies have been used. Sutureless repair is currently most commonly used, but patch venoplasty, endarterectomy, ostial resection, and reimplantation are used in select circumstances as well. Medical therapies such as imatinib mesylate and bevacizumab are increasingly being used in an effort to suppress the myofibroblastic proliferation seen in PVS patients. Lung transplantation has been used as an alternative treatment strategy for end-stage, refractory PVS. Nonetheless, despite the different innovative approaches used, morbidity and mortality remain high. At present, the preferred treatment strategy is frequent reassessment of disease progression to guide use of catheter-based and surgical interventions in conjunction with medical therapy.


Assuntos
Veias Pulmonares , Pneumopatia Veno-Oclusiva , Fatores Etários , Criança , Pré-Escolar , Constrição Patológica , Humanos , Incidência , Lactente , Recém-Nascido , Veias Pulmonares/diagnóstico por imagem , Pneumopatia Veno-Oclusiva/diagnóstico por imagem , Pneumopatia Veno-Oclusiva/etiologia , Pneumopatia Veno-Oclusiva/mortalidade , Pneumopatia Veno-Oclusiva/terapia , Fatores de Risco , Resultado do Tratamento
4.
Anesth Analg ; 127(3): 724-729, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29734243

RESUMO

BACKGROUND: While mortality and adverse perioperative events after noncardiac surgery in children with a broad range of congenital cardiac lesions have been investigated using large multiinstitutional databases, to date single-center studies addressing adverse outcomes in children with congenital heart disease (CHD) undergoing noncardiac surgery have only included small numbers of patients with significant heart disease. The primary objective of this study was to determine the incidences of perioperative cardiovascular and respiratory events in a large cohort of patients from a single institution with a broad range of congenital cardiac lesions undergoing noncardiac procedures and to determine risk factors for these events. METHODS: We identified 3010 CHD patients presenting for noncardiac procedures in our institution over a 5-year period. We collected demographic information, including procedure performed, cardiac diagnosis, ventricular function as assessed by echocardiogram within 6 months of the procedure, and classification of CHD into 3 groups (minor, major, or severe CHD) based on residual lesion burden and cardiovascular functional status. Characteristics related to conduct of anesthesia care were also collected. The primary outcome variables for our analysis were the incidences of intraoperative cardiovascular and respiratory events. Univariable and multivariable logistic regressions were used to determine risk factors for these 2 outcomes. RESULTS: The incidence of cardiovascular events was 11.5% and of respiratory events was 4.7%. Univariate analysis and multivariable analysis demonstrated that American Society of Anesthesiologists (≥3), emergency cases, major and severe CHD, single-ventricle physiology, ventricular dysfunction, orthopedic surgery, general surgery, neurosurgery, and pulmonary procedures were associated with perioperative cardiovascular events. Respiratory events were associated with American Society of Anesthesiologists (≥4) and otolaryngology, gastrointestinal, general surgery, and maxillofacial procedures. CONCLUSIONS: Intraoperative cardiovascular events and respiratory events in patients with CHD were relatively common. While cardiovascular events were highly associated with cardiovascular status, respiratory events were not associated with cardiovascular status.


Assuntos
Doenças Cardiovasculares/epidemiologia , Cardiopatias Congênitas/epidemiologia , Cardiopatias Congênitas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Transtornos Respiratórios/epidemiologia , Doenças Cardiovasculares/diagnóstico , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais/tendências , Feminino , Cardiopatias Congênitas/diagnóstico , Humanos , Incidência , Lactente , Masculino , Complicações Pós-Operatórias/diagnóstico , Transtornos Respiratórios/diagnóstico , Fatores de Risco
5.
Anesth Analg ; 125(3): 1078-1079, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28817533
6.
Catheter Cardiovasc Interv ; 88(6): 912-922, 2016 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-27801973

RESUMO

Current practice of sedation and anesthesia for patients undergoing pediatric congenital cardiac catheterization laboratory (PCCCL) procedures is known to vary among institutions, a multi-society expert panel with representatives from the Congenital Heart Disease Council of the Society for Cardiovascular Angiography and Interventions (SCAI), the Society for Pediatric Anesthesia (SPA) and the Congenital Cardiac Anesthesia Society (CCAS) was convened to evaluate the types of sedation and personnel necessary for procedures performed in the PCCCL. The goal of this panel was to provide practitioners and institutions performing these procedures with guidance consistent with national standards and to provide clinicians and institutions with consensus-based recommendations and the supporting references to encourage their application in quality improvement programs. Recommendations can neither encompass all clinical circumstances nor replace the judgment of individual clinicians in the management of each patient. The science of medicine is rooted in evidence, and the art of medicine is based on the application of this evidence to the individual patient. This expert consensus statement has adhered to these principles for optimal management of patients requiring sedation and anesthesia. What follows are recommendations for patient monitoring in the PCCCL regardless of whether minimal or no sedation is being used or general anesthesia is being provided by an anesthesiologist. © 2016 Wiley Periodicals Inc.


Assuntos
Anestesia Geral/normas , Cateterismo Cardíaco , Sedação Consciente/normas , Consenso , Cardiopatias Congênitas/cirurgia , Guias de Prática Clínica como Assunto , Angiografia , Criança , Cardiopatias Congênitas/diagnóstico , Humanos
7.
Anesth Analg ; 123(5): 1201-1209, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27749349

RESUMO

Current practice of sedation and anesthesia for patients undergoing pediatric and congenital cardiac catheterization laboratory (PCCCL) procedures is known to vary among institutions, a multi-society expert panel with representatives from the Congenital Heart Disease Council of the Society for Cardiovascular Angiography and Interventions, the Society for Pediatric Anesthesia and the Congenital Cardiac Anesthesia Society was convened to evaluate the types of sedation and personnel necessary for procedures performed in the PCCCL. The goal of this panel was to provide practitioners and institutions performing these procedures with guidance consistent with national standards and to provide clinicians and institutions with consensus-based recommendations and the supporting references to encourage their application in quality improvement programs. Recommendations can neither encompass all clinical circumstances nor replace the judgment of individual clinicians in the management of each patient. The science of medicine is rooted in evidence, and the art of medicine is based on the application of this evidence to the individual patient. This expert consensus statement has adhered to these principles for optimal management of patients requiring sedation and anesthesia. What follows are recommendations for patient monitoring in the PCCCL regardless of whether minimal or no sedation is being used or general anesthesia is being provided by an anesthesiologist.


Assuntos
Anestesia Geral/normas , Cateterismo Cardíaco/normas , Sedação Consciente/normas , Cardiopatias Congênitas/terapia , Guias de Prática Clínica como Assunto/normas , Sociedades Médicas/normas , Anestesia Geral/métodos , Anestesiologia/métodos , Anestesiologia/normas , Criança , Sedação Consciente/métodos , Consenso , Cardiopatias Congênitas/diagnóstico , Humanos
8.
Ann Thorac Surg ; 102(4): 1360-7, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27234574

RESUMO

BACKGROUND: Children with congenital heart disease are at increased risk of thrombotic complications (thrombosis and thromboembolism). This study sought to assess the incidence and predictors of thrombotic complications in children with surgical and nonsurgical heart diseases. METHODS: We performed a retrospective analysis of the Health Care Cost and Use Project Kid's Inpatient Database. Children with surgical and nonsurgical heart diseases were categorized into the following four subgroups: (1) septal defects, (2) single ventricle physiology, (3) right ventricle outflow tract obstruction, and (4) left ventricle outflow tract obstruction. Demographic information, comorbidities, and outcomes, such as mortality, acute kidney injury, sepsis, neurologic complications, thrombotic complications, extracorporeal membrane oxygenation, and ventricular assist device use, were identified. We used propensity-matched analysis and multivariate logistic regression analysis to determine the variables associated with thrombotic complications. RESULTS: After propensity-matched analysis, the incidence of thrombotic complications was 3.90% (947/24,251) in children with surgical and 2.13% (516/24,251) in children with nonsurgical heart disease (p < 0.001). Multivariate logistic regression analysis revealed that single ventricle physiology or right ventricle outflow tract obstruction, extracorporeal membrane oxygenation, ventricular assist device, acute kidney injury, sepsis, and the presence of a coagulopathy increased the risk of thrombotic complications in children with surgical or nonsurgical heart disease. Age younger than 1 year increased the risk of thrombotic complications in the surgical population, whereas age older than 12 years increased the risk in the nonsurgical population. CONCLUSIONS: Children with both surgical and nonsurgical heart disease have increased risk of thrombotic complications. The risk is increased in patients with cyanotic heart disease and is highest in the presence of single ventricle physiology.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Cardiopatias Congênitas/terapia , Complicações Pós-Operatórias/epidemiologia , Trombose/epidemiologia , Criança , Pré-Escolar , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Massachusetts/epidemiologia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo
9.
Anesth Analg ; 122(2): 482-9, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26554463

RESUMO

BACKGROUND: Pediatric anesthesia-related cardiac arrest (ARCA) is an uncommon but potentially preventable adverse event. Infants and children with more severe underlying disease are at highest risk. We aimed to identify system- and anesthesiologist-related risk factors for ARCA. METHODS: We analyzed a prospectively collected patient cohort data set of anesthetics administered from 2000 to 2011 to children at a large tertiary pediatric hospital. Pre-procedure systemic disease level was characterized by ASA physical status (ASA-PS). Two reviewers independently reviewed cardiac arrests and categorized their anesthesia relatedness. Factors associated with ARCA in the univariate analyses were identified for reevaluation after adjustment for patient age and ASA-PS. RESULTS: Cardiac arrest occurred in 142 of 276,209 anesthetics (incidence 5.1/10,000 anesthetics); 72 (2.6/10,000 anesthetics) were classified as anesthesia-related. In the univariate analyses, risk of ARCA was much higher in cardiac patients and for anesthesiologists with lower annual caseload and/or fewer annual days delivering anesthetics (all P < 0.001). Anesthesiologists with the highest academic rank and years of experience also had higher odds of ARCA (P = 0.02). After risk adjustment for ASA-PS ≥ III and age ≤ 6 months, however, the association with lower annual days delivering anesthetics remained (P = 0.03), but the other factors were no longer significant. CONCLUSIONS: Case-mix explained most associations between higher risk of pediatric ARCA and anesthesiologist-related variables at our institution, but the association with fewer annual days delivering anesthetics remained. Our findings highlight the need for rigorous adjustment for patient risk factors in anesthesia patient safety studies.


Assuntos
Anestesia/efeitos adversos , Parada Cardíaca/induzido quimicamente , Parada Cardíaca/epidemiologia , Adolescente , Fatores Etários , Anestesiologia/educação , Criança , Pré-Escolar , Estudos de Coortes , Mortalidade Hospitalar , Humanos , Incidência , Lactente , Recém-Nascido , Segurança do Paciente , Pediatria , Estudos Prospectivos , Risco Ajustado , Fatores de Risco
10.
Paediatr Anaesth ; 25(8): 846-851, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25970232

RESUMO

BACKGROUND: Patients with single ventricle physiology are at increased anesthetic risk when undergoing noncardiac surgery. OBJECTIVE: To review the outcomes of anesthetics for patients with single ventricle physiology undergoing noncardiac surgery. METHODS: This study is a retrospective chart review of all patients who underwent a palliative procedure for single ventricle physiology between January 1, 2007 and January 31, 2014. Anesthetic and surgical records were reviewed for noncardiac operations that required sedation or general anesthesia. Any noncardiac operation occurring prior to completion of a bidirectional Glenn procedure was included. Diagnostic procedures, including cardiac catheterization, insertion of permanent pacemaker, and procedures performed in the ICU, were excluded. RESULTS: During the review period, 417 patients with single ventricle physiology had initial palliation. Of these, 70 patients (16.7%) underwent 102 anesthetics for 121 noncardiac procedures. The noncardiac procedures included line insertion (n = 23); minor surgical procedures such as percutaneous endoscopic gastrostomy or airway surgery (n = 38); or major surgical procedures including intra-abdominal and thoracic operations (n = 41). These interventions occurred on median day 60 of life (1-233 days). The procedures occurred most commonly in the operating room (n = 79, 77.5%). Patients' median weight was 3.4 kg (2.4-15 kg) at time of noncardiac intervention. In 102 anesthetics, 26 patients had an endotracheal tube or tracheostomy in situ, 57 patients underwent endotracheal intubation, and 19 patients had a natural or mask airway. An intravenous induction was performed in 77 anesthetics, an inhalational induction in 17, and a combination technique in 8. The median total anesthetic time was 126 min (14-594 min). In 22 anesthetics (21.6%), patients were on inotropic support upon arrival; an additional 24 patients required inotropic support (23.5%), of which dopamine was the most common medication. There were 10 intraoperative adverse events (9.8%) including: arrhythmias requiring treatment (n = 4), conversion from sedation to a general anesthetic (n = 2), difficult airway (n = 1), inadvertent extubation with desaturation and bradycardia (n = 1), hypotension and desaturation (n = 1), and cardiac arrest (n = 1). Postoperative events (<48 h) included ST segment changes requiring cardiac catheterization (n = 1), and cardiorespiratory arrest (n = 1). Age, size, gender, type of cardiac palliation, patient location, procedure location, and type of procedure were not associated with adverse outcome. After 62 anesthetics (60.8%), patients went postoperatively to the cardiac ICU. There were no deaths at 48 h. CONCLUSION: We observed no mortality during or after noncardiac surgery in a high-risk subgroup of palliated cardiac patients with single ventricle physiology. However, 11.8% of patients had an adverse event associated with their anesthetic.


Assuntos
Anestesia/efeitos adversos , Cardiopatias Congênitas/epidemiologia , Ventrículos do Coração/anormalidades , Complicações Intraoperatórias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Técnica de Fontan , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/métodos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
11.
Anesth Analg ; 118(1): 175-82, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23749445

RESUMO

BACKGROUND: Cardiac catheterization for patients with congenital heart disease has shifted from diagnostic to predominantly interventional procedures because of advances in catheter-based technologies. Children undergoing therapeutic catheterization may be at higher risk of adverse events, and the purpose of our study was to determine the incidence of cardiac arrest (CA) in patients with congenital heart disease undergoing cardiac catheterization at a large pediatric tertiary referral center. METHODS: All CAs from January 2004 through December 2009 occurring in the cardiac catheterization laboratory were reviewed. A CA was defined as an event in which cessation of circulation required chest compressions. Procedure, patient, practitioner, and system-related factors were examined. RESULTS: Over the study period, during 7289 catheterization procedures, 70 procedures were associated with a CA (0.96 [99% confidence interval, 0.7-1.3] per 100 procedures); 48 events (69%) were successfully resuscitated to a perfusing rhythm, 18 events (26%) resulted in need for extracorporeal membrane oxygenation, and 4 events (6%) resulted in unsuccessful resuscitation. Sudden onset of cardiac arrhythmia led to CA during 38 events (54%). The duration of resuscitation after CA was ≤11 minutes in 71%. Occurrence of CA was associated with interventional procedures (P < 0.001) and younger age (P < 0.001). A change in systems for scheduling and communication of cases was associated with a significant reduction in the incidence of CA (1.5% vs 0.7%; P = 0.002). CONCLUSIONS: The incidence of CA in children undergoing cardiac catheterization is high compared with pediatric noncardiac surgery. Procedural and system factors were associated with occurrence of CA in this cohort. These issues highlight the need for close communication, anticipation, and preparation.


Assuntos
Cateterismo Cardíaco/efeitos adversos , Parada Cardíaca/diagnóstico , Parada Cardíaca/epidemiologia , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/epidemiologia , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Feminino , Cardiopatias Congênitas/terapia , Humanos , Lactente , Recém-Nascido , Masculino , Resultado do Tratamento
12.
J Thorac Cardiovasc Surg ; 146(5): 1172-8, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23380513

RESUMO

OBJECTIVES: A previously published randomized clinical trial comparing cardiac magnetic resonance (CMR) versus routine catheterization in patients with functional single ventricle before bidirectional Glenn (BDG) operation demonstrated similar short-term post-BDG outcomes. We sought to assess late outcomes in this cohort to ascertain any long-term effects of this evaluation strategy. METHODS: Retrospective review of enrolled patients through most recent follow-up was performed on all 82 patients in the original cohort, at a median age of 8.8 years. RESULTS: Of these, 76 (93%) underwent Fontan operation; 2 died before Fontan. Baseline demographics, anatomic factors, and age at BDG did not differ between those randomized to CMR versus catheterization. Although pre-BDG CMR patients were younger at Fontan (2.4 vs 2.7 years; P = .02), baseline weight, body surface area, oxygen saturation, ventricular function, and degree of atrioventricular valve regurgitation were similar. Catheterization before Fontan (n = 76) demonstrated similar hemodynamic parameters including pulmonary vascular resistance and mean pulmonary artery, atrial, and ventricular end-diastolic pressures. CMR patients had comparable rates of transcatheter interventions (71% vs 79%; P = .6), including coil occlusion of systemic-pulmonary collaterals (66% vs 61%; P = .29). At Fontan surgery, short-term complications, hospital length of stay, and the percent meeting a 5-part definition of successful Fontan operation were not different (71% vs 55%; P = .23). CONCLUSIONS: Pre-BDG CMR and catheterization groups had equivalent clinical and hemodynamic profiles before Fontan and similar post-Fontan outcomes at a median follow-up of 8 years after BDG. For selected patients, a pre-BDG evaluation with CMR is an acceptable alternative to catheterization.


Assuntos
Cateterismo Cardíaco , Técnica de Fontan , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/cirurgia , Hemodinâmica , Imagem por Ressonância Magnética , Pré-Escolar , Feminino , Técnica de Fontan/efeitos adversos , Técnica de Fontan/mortalidade , Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/fisiopatologia , Humanos , Masculino , Valor Preditivo dos Testes , Cuidados Pré-Operatórios , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
13.
World J Pediatr Congenit Heart Surg ; 3(4): 470-91, 2012 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-23804911

RESUMO

Children in the cardiac intensive care unit (CICU) with congenital or acquired heart disease are at risk for hematologic complications, both hemorrhage and thrombosis. The overall incidence of hematologic complications in the CICU is unknown, but risk factors and target groups have been identified where the essential physiologic balance between bleeding and clotting has been disrupted. Although the best management of life-threatening bleeding and clotting is prevention, the cardiac intensivist is often faced with managing life-threatening hematologic events involving patients from within the unit or those who present from outside. Part I of this review deals with the propensity of children with congenital and acquired heart disease to complications of both bleeding and clotting, and includes discussions of perioperative bleeding, thromboses in single-ventricle patients, clotting of Blalock-Taussig shunts and thrombotic complications of mechanical valves. Part II deals with the subject of stroke in children with heart disease. Part III reviews monitoring the effectiveness of anticoagulation and thrombolysis in the CICU. Currently available diagnostics modalities, medications and management strategies are reviewed and future directions discussed.

14.
Paediatr Anaesth ; 19(9): 854-61, 2009 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-19691693

RESUMO

OBJECTIVES: Despite aggressive measures to miniaturize the cardiopulmonary bypass (CPB) circuit in neonates and infants, the CPB prime volume is often at least as large as the patients' blood volume. We conducted an observational study to characterize the hemostatic consequences of a CPB prime consisting of either non-fresh or reconstituted whole blood. METHODS: Hematocrit, fibrinogen, platelet count, plasminogen, anti-thrombin III (AT-III), and factors (F) II, V, VII, IX, and X of 30 neonates and infants undergoing cardiac surgery with CPB utilizing either a non-fresh or reconstituted whole blood prime were prospectively evaluated at eight time points. Following protamine administration, microvascular bleeding was treated by protocol. RESULTS: The hemostatic composition of the CPB prime was the same following the use of either non-fresh or reconstituted whole blood. The CPB prime platelet count (mean +/- SD) was 5.87 +/- 2.84 x 10(3) microl(-1) when compared to a preoperative platelet count of 298 +/- 142 x 10(3) microl(-1) (P < 0.0001). Twenty patients received 17.3 +/- 9.2 ml x kg(-1) (0.86 +/- 0.46 units x kg(-1)) of platelets with significant improvement in platelet count. Nine patients received 16.7 +/- 13.4 ml x kg(-1) (0.84 +/- 0.67 units x kg(-1)) of cryoprecipitate with significant improvements in FVIII and fibrinogen. CONCLUSIONS: Non-fresh or reconstituted whole blood as a component of a small volume CPB prime in neonates and infants induces clinically significant dilutional thrombocytopenia in conjunction with less significant reductions in fibrinogen, FII, FV, FVII, FVIII, FIX, FX, plasminogen, and AT-III.


Assuntos
Transfusão de Sangue , Ponte Cardiopulmonar/métodos , Hemostasia Cirúrgica/métodos , Algoritmos , Análise Química do Sangue , Perda Sanguínea Cirúrgica , Preservação de Sangue , Volume Sanguíneo , Colágeno Tipo VIII/metabolismo , Feminino , Fibrinogênio/metabolismo , Hematócrito , Antagonistas de Heparina/farmacologia , Humanos , Lactente , Recém-Nascido , Masculino , Modelos Estatísticos , Contagem de Plaquetas , Protaminas/farmacologia , Trombocitopenia/sangue , Trombocitopenia/etiologia
15.
J Thorac Cardiovasc Surg ; 137(4): 934-41, 2009 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-19327521

RESUMO

OBJECTIVE: The risk for thrombosis is increased after the Fontan operation. It is unknown whether children with univentricular heart disease have an intrinsic coagulation anomaly or acquire a defect in coagulation during the course of the staged repair. This prospective, longitudinal study evaluated changes in coagulation profiles in a cohort of patients with hypoplastic left heart syndrome from stage I palliation through completion of the Fontan operation. METHODS: Thirty-seven patients with hypoplastic left heart syndrome were enrolled prospectively, and the concentration of factors II, V, VII, VIII, IX, X, proteins C and S, fibrinogen, antithrombin, serum albumin, and liver enzymes were measured before stage I palliation (mean age 4 +/- 2 days), before bidirectional Glenn (mean age 5.9 +/- 1.8 months), before the Fontan procedure (mean age 27.1 +/- 6.6 months), and after the Fontan procedure (mean age 49 +/- 17.6 months). Healthy children were used as age-matched controls for coagulation factors. Demographic, hemodynamic variables, and elapsed time after the Fontan procedure were evaluated as possible predictors of coagulation abnormalities. RESULTS: Significantly lower levels of both procoagulation and anticoagulation factors were demonstrated through to completion of the Fontan procedure. After the Fontan procedure, there was a significantly higher factor VIII level (P < .005) but no correlation with hemodynamic variables or liver function. CONCLUSION: This longitudinal study in patients with identical cardiac disease and staged surgical procedures confirms the increase in factor VIII level after the Fontan procedure. This is an acquired defect, and although the cause remains to be determined, monitoring factor VIII levels after the Fontan operation could indicate a subset of patients at risk for thrombosis.


Assuntos
Transtornos da Coagulação Sanguínea/etiologia , Técnica de Fontan/efeitos adversos , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Trombose/etiologia , Transtornos da Coagulação Sanguínea/diagnóstico , Testes de Coagulação Sanguínea , Criança , Pré-Escolar , Fator VIII/análise , Humanos , Síndrome do Coração Esquerdo Hipoplásico/complicações , Lactente , Recém-Nascido , Estudos Prospectivos
16.
Cardiol Young ; 18(3): 307-10, 2008 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-18460227

RESUMO

BACKGROUND: Cardiac anomalies are among the most frequent congenital malformations, but the basic underlying causes for most cardiac defects remains undetermined. Some 40 years ago, a higher incidence of blood group B was reported in a small number of African-American children with congenital cardiac defects. In this study, we sought to re-evaluate this association using a larger population. METHODS AND RESULTS: We collected data from 1985 patients undergoing cardiac surgery from July, 2000, through December, 2004. We divided the patients into 6 subgroups according to their diagnosis. We then compared the prevalence of ABO phenotypes between the patients and the general population of the United States of America by chi-square analysis. There were no significant differences in the distribution of the ABO phenotypes amongst the subgroups of those with congenital cardiac disease, or any for subgroup compared to the general population. CONCLUSION: While statistical significance is influenced by the size of the population within the United States of America and the small numbers within each of our subgroups of patients with congenital cardiac disease, we have been unable to show any relationship between the distribution of ABO phenotypes and the existence of congenital cardiac disease.


Assuntos
Sistema ABO de Grupos Sanguíneos , Cardiopatias Congênitas/sangue , Feminino , Humanos , Masculino
17.
Circulation ; 116(23): 2718-25, 2007 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-18025538

RESUMO

BACKGROUND: Routine preoperative catheterization is standard practice in patients with single-ventricle physiology before bidirectional Glenn anastomosis. Because catheterization is invasive and exposes patients to ionizing radiation, cardiac magnetic resonance (CMR) may be a safe and effective alternative. METHODS AND RESULTS: We conducted a prospective, randomized, single-center clinical trial comparing catheterization with CMR in patients considered for bidirectional Glenn operation from February 2003 to June 2006. End points were frequency of adverse events of the preoperative evaluation and a composite score of clinically successful surgery. Of 92 eligible patients, 82 were enrolled on the basis of screening echocardiogram, fulfillment of inclusion criteria, and informed consent. Patients were randomized to catheterization (n=41) or CMR (n=41). There were no baseline differences between groups. Four treatment crossovers occurred, 3 to catheterization and 1 to CMR. Catheter interventions were performed in 17 patients (41%). Catheterization resulted in more minor adverse events (78% versus 5%; P<0.001), longer preoperative hospital stays (median, 2 versus 1 day; P<0.001), and higher hospital charges ($34 477 versus $14 921; P<0.001). There was 1 major adverse event in the CMR group (P=1.0). The operative course and frequency of postoperative complications were similar between the 2 groups. The proportion of patients who had a successful bidirectional Glenn operation was similar (71% versus 83%; P=0.3). At the 3-month follow-up, there were no differences in clinical status, oxygen saturation, or frequency of reinterventions. CONCLUSIONS: CMR is a safe, effective, and less costly alternative to routine catheterization in the evaluation of selected patients before bidirectional Glenn operation. Further studies are necessary to determine whether there are long-term benefits from transcatheter interventions in these patients.


Assuntos
Cateterismo Cardíaco , Cardiopatias Congênitas/diagnóstico por imagem , Imagem por Ressonância Magnética , Anastomose Cirúrgica/economia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/economia , Criança , Pré-Escolar , Feminino , Seguimentos , Cardiopatias Congênitas/economia , Cardiopatias Congênitas/fisiopatologia , Cardiopatias Congênitas/cirurgia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Ventrículos do Coração/cirurgia , Humanos , Lactente , Tempo de Internação/economia , Imagem por Ressonância Magnética/efeitos adversos , Imagem por Ressonância Magnética/economia , Masculino , Estudos Prospectivos , Radiografia
18.
J Cardiovasc Magn Reson ; 9(5): 793-8, 2007.
Artigo em Inglês | MEDLINE | ID: mdl-17891617

RESUMO

PURPOSE: To assess the incidence and severity of adverse events (AE) associated with cardiovascular magnetic resonance (CMR) in a large cohort of patients with congenital heart disease and to identify independent risk factors for their occurrence. METHODS: AEs were prospectively recorded from October 2002 through December 2004 and graded by 3 independent observers for severity, preventability, and attributability. The rate of adverse events was analyzed for each candidate variable using Fisher's exact test and independent predictors were identified by multiple logistic regression analysis. RESULTS: There were 22 AEs among 1334 CMR studies (1.6%); 14 (63.5%) minor, 7 (32%) moderate, and 1 (4.5%) major. General anesthesia (GA) was used in 274 studies (20.5%) with 12 AEs (4.4%, p<0.001). There were 7 AEs (6.3%, p=0.001) in 112 studies on hospitalized patients, 5 AEs (5.2%, p=0.018) in 97 patients under 1 year of age, and 3 AEs (2.2%, p=0.479) in 134 patients with functional single ventricle. The highest rate of AEs was noted in inpatients under GA (10.4%, p<0.001); most were in the intensive care unit. Use of anesthesia (OR 3.91 [95% CI 1.46, 10.48] p=0.007) and inpatient status (OR 3.56 [95% CI 1.16, 10.89], p=0.026) were independent predictors of AEs. CONCLUSIONS: CMR in patients with congenital heart disease has a low rate of AEs. Use of GA and examinations on hospitalized patients are independent risk factors for AEs with the most acutely ill patients at highest risk.


Assuntos
Meios de Contraste/efeitos adversos , Gadolínio/efeitos adversos , Cardiopatias Congênitas/diagnóstico , Imagem por Ressonância Magnética/efeitos adversos , Adolescente , Adulto , Idoso , Anestesia Geral/efeitos adversos , Criança , Pré-Escolar , Feminino , Nível de Saúde , Humanos , Incidência , Lactente , Recém-Nascido , Pacientes Internados , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Prospectivos , Projetos de Pesquisa , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença
19.
Anesth Analg ; 105(2): 335-43, 2007 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-17646487

RESUMO

BACKGROUND: The frequency of anesthesia-related cardiac arrests during pediatric anesthesia has been reported between 1.4 and 4.6 per 10,000 anesthetics. ASA physical status >III and younger age are risk factors. Patients with congenital cardiac disease may also be at increased risk. Therefore, in this study, we evaluated the frequency of cardiac arrest in patients with congenital heart disease undergoing cardiac surgery at a large pediatric tertiary referral center. METHODS: Using an established data registry, all cardiac arrests from January 2000 through December 2005 occurring in the cardiac operating rooms were reviewed. A cardiac arrest was defined as any event requiring external or internal chest compressions, with or without direct cardioversion. Events determined to be anesthesia-related were classified as likely related or possibly related. RESULTS: There were 41 cardiac arrests in 40 patients (median age, 2.9 mo; range, 2 days to 23 yr) during 5213 anesthetics over the time period, for an overall frequency of 0.79%; 78% were open procedures requiring cardiopulmonary bypass and 22% closed procedures not requiring cardiopulmonary bypass. Eleven cardiac arrests (26.8%) were classified as either likely (n = 6) or possibly related (n = 5) to anesthesia, (21.1 per 10,000 anesthetics) but with no mortality; 30 were categorized as procedure-related. The incidence of anesthesia-related and procedure-related cardiac arrests was highest in neonates (P < 0.001). There was no association with year of event or experience of the anesthesiologist. CONCLUSION: The frequency of anesthesia-related cardiac arrest in patients undergoing cardiac surgery is increased, but is not associated with an increase in mortality. Neonates and infants are at higher risk. Careful preparation and anticipation is important to ensure timely and effective resuscitation.


Assuntos
Anestesia/efeitos adversos , Procedimentos Cirúrgicos Cardiovasculares/efeitos adversos , Parada Cardíaca/epidemiologia , Parada Cardíaca/etiologia , Cardiopatias Congênitas/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/epidemiologia , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Sistema de Registros , Estudos Retrospectivos
20.
Anesth Analg ; 105(2): 365-8, 2007 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-17646491

RESUMO

BACKGROUND: Ultrasound is increasingly used to facilitate right internal jugular vein (RIJV) cannulation in children. In children without cardiac disease, position changes and enhancement maneuvers increase RIJV cross-sectional area (CSA) and further facilitate cannulation. We investigated the effect of these maneuvers on RIJV CSA in children with a bidirectional Glenn (BDG) shunt presenting for a Fontan procedure. METHODS: The CSA (cm(2)) of the RIJV in 21 children with a BDG shunt presenting for a Fontan procedure was assessed by ultrasonic planimetry (SonoSite). Two positions, supine (S) and 15 degrees Trendelenburg (T); and two enhancements maneuvers, manual liver compression (L) and a simulated Valsalva maneuver (V) were utilized in combination. Eight separate measurements (S, S + L, S + V, S + L + V, T, T + L, T + V, T + L + V) were made in each patient. Data were analyzed using one-way analysis of variance with repeated measures and with Tukey post hoc pairwise comparison analysis. RESULTS: No significant change in the RIJV CSA or % change in CSA from baseline (S) was observed. CONCLUSIONS: Position changes and enhancement maneuvers are unlikely to facilitate RIJV cannulation in BDG shunt patients presenting for Fontan procedure because these interventions do not increase RIJV CSA.


Assuntos
Cateterismo Venoso Central/métodos , Decúbito Inclinado com Rebaixamento da Cabeça/fisiologia , Veias Jugulares/fisiologia , Fígado/fisiologia , Manobra de Valsalva/fisiologia , Cateterismo Venoso Central/instrumentação , Pré-Escolar , Feminino , Derivação Cardíaca Direita/instrumentação , Derivação Cardíaca Direita/métodos , Humanos , Lactente , Masculino , Vasodilatação/fisiologia
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