RESUMO
OBJECTIVES: Fluid overload after pediatric cardiac surgery is common and has been shown to increase both mortality and morbidity. This study explores the risk factors of early postoperative fluid overload and its relationship with adverse outcomes. DESIGN: Secondary analysis of the prospectively collected data of children undergoing open-heart surgery between 2004 and 2008. SETTING: Tertiary national cardiac center. PATIENTS: One thousand five hundred twenty consecutive pediatric patients (<18 years old) were included in the analyses. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In the first 72 hours of the postoperative period, the daily fluid balance was calculated as milliliter per kilogram and the daily fluid overload was calculated as fluid balance (L)/weight (kg) × 100. The primary endpoint was in-hospital mortality; the secondary outcomes were low cardiac output syndrome and prolonged mechanical ventilation. One thousand three hundred and sixty-seven patients (89.9%) had a cumulative fluid overload below 5%; 120 patients (7.8%), between 5% and 10%; and 33 patients (2.1%), above 10%. After multivariable analysis, higher fluid overload on the day of the surgery was independently associated with mortality (adjusted odds ratio, 1.14; 95% CI, 1.008-1.303; p = 0.041) and low cardiac output syndrome (adjusted odds ratio, 1.21; 95% CI, 1.12-1.30; p = 0.001). Higher maximum serum creatinine levels (adjusted odds ratio, 1.01; 95% CI, 1.003-1.021; p = 0.009), maximum vasoactive-inotropic scores (adjusted odds ratio, 1.01; 95% CI, 1.005-1.029; p = 0.042), and higher blood loss on the day of the surgery (adjusted odds ratio, 1.01; 95% CI, 1.004-1.025; p = 0.015) were associated with a higher risk of fluid overload that was greater than 5%. CONCLUSIONS: Fluid overload in the early postoperative period was associated with higher mortality and morbidity. Risk factors for fluid overload include underlying kidney dysfunction, hemodynamic instability, and higher blood loss on the day of the surgery.
Assuntos
Baixo Débito Cardíaco/epidemiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/mortalidade , Respiração Artificial/estatística & dados numéricos , Desequilíbrio Hidroeletrolítico/complicações , Líquidos Corporais , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Desequilíbrio Hidroeletrolítico/mortalidadeRESUMO
INTRODUCTION: Afew data have been published on the clinical characteristics of different types of myocardial infarction in Hungary. AIM: To compare clinical data of patients with ST-segment elevation and non-ST-segment elevation myocardial infarction based on the National Myocardial Infarction Registry database. METHOD: Data recorded in the National Myocardial Infarction Registry between January 1, 2010 and June 30, 2012 were included in the analysis. RESULTS: Patients treated with non-ST-segment elevation myocardial infarction (n = 5237) were older and had more comorbidities compared to those with ST-segment elevation myocardial infarction (n = 6670). Coronarography and percutaneous coronary intervention were performed more frequently in the latter group. There was no significant difference in in-hospital mortality between the two groups (5.3% and 4.9%). Medication for secondary prevention after myocardial infarction was applied in nearly 90% of the patients in both groups. Dual antiplatelet therapy was more often applied after ST-segment elevation myocardial infarction. CONCLUSIONS: The study confirmed important differences in the clinical characteristics and similar hospital prognosis between the two patient groups.
Assuntos
Cuidados Críticos/métodos , Sistema de Condução Cardíaco/fisiopatologia , Hospitalização , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/terapia , Antagonistas Adrenérgicos beta/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia Coronária com Balão , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Angiografia Coronária , Feminino , Mortalidade Hospitalar , Humanos , Hungria/epidemiologia , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/fisiopatologia , Inibidores da Agregação Plaquetária/uso terapêutico , Sistema de RegistrosRESUMO
OBJECTIVE: Although the lysine analogs tranexamic acid (TXA) and aminocaproic acid (EACA) are used widely for antifibrinolytic therapy in cardiac surgery, relatively little research has been performed on their safety profiles, especially in the setting of cardiac surgery. Two antifibrinolytic protocols using either TXA or aminocaproic acid were compared according to postoperative outcome. DESIGN: A retrospective analysis. SETTING: A university-affiliated hospital. PARTICIPANTS: Six hundred four patients undergoing cardiac surgery. INTERVENTIONS: One cohort of 275 consecutive patients received TXA; a second cohort of 329 consecutive patients was treated with EACA. Except for antifibrinolytic therapy, the anesthetic and surgical teams and their protocols remained unchanged. MEASUREMENTS AND MAIN RESULTS: Besides major outcome criteria, namely postoperative bleeding, the need for allogeneic transfusions, operative revision because of bleeding, postoperative renal dysfunction, neurologic events, heart failure, and in-hospital mortality, the authors specifically sought differences between the groups concerning seizures. The 2 cohorts were comparable over a range of perioperative factors. Postoperative seizures occurred significantly more frequently in TXA patients (7.6% v 3.3%, p = 0.019), whereas EACA patients had a higher incidence of postoperative renal dysfunction (20.0% v 30.1%, p = 0.005). There were no differences in all other measured major outcome factors. CONCLUSION: Both lysine analogs are associated with significant side effects, which must be taken into account when performing risk-benefit analyses of their use. Their use should be restricted to patients at high risk for bleeding; routine use on low-risk patients undergoing standard surgeries should face renewed critical reappraisal.
Assuntos
Ácido Aminocaproico/efeitos adversos , Antifibrinolíticos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Convulsões/epidemiologia , Ácido Tranexâmico/efeitos adversos , Idoso , Ácido Aminocaproico/uso terapêutico , Anestesia , Antifibrinolíticos/uso terapêutico , Perda Sanguínea Cirúrgica/prevenção & controle , Estudos de Coortes , Ponte de Artéria Coronária , Feminino , Mortalidade Hospitalar , Humanos , Ataque Isquêmico Transitório/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Acidente Vascular Cerebral/epidemiologia , Ácido Tranexâmico/uso terapêutico , Resultado do TratamentoRESUMO
Measurement of the global end-diastolic volume index (GEDI) by transpulmonary thermodilution (TPTD) has become a useful technique for measuring preload in adults. This study aimed to investigate the hemodynamic changes in neonates during the postoperative period after arterial switch surgery. Over a 13-month period, the postoperative data of 12 neonates with transposition of the great arteries were retrospectively investigated. Arterial and central venous blood pressures were monitored, Cardiac index (CI), stroke volume index (SVI), systemic vascular resistance index (SVRI), GEDI, and extravascular lung water index (ELWI) were measured by thermodilution. The CI was significantly correlated with the SVRI only in the closed chest condition (r = -0.92; P < 0.001). The CI and SVI values were significantly lower and the ELWI and SVRI values significantly higher in both the open and closed chest conditions than the postextubation values. The relationship between change in GEDI and change in CI was stronger in the open chest condition (r = 0.93; P < 0.006) than in the closed chest condition (r = 0.75; P = 0.055). However, the latter just missed statistical significance. According to the findings, TPTD seems to be a useful tool for assessing cardiac function after neonatal arterial switch surgery. Establishment of normal values will be essential for proper guidance of therapy for this population using volumetric parameters.
Assuntos
Artérias , Procedimentos Cirúrgicos Cardíacos/métodos , Pulmão , Transposição dos Grandes Vasos/cirurgia , Fatores Etários , Análise de Variância , Procedimentos Cirúrgicos Cardíacos/instrumentação , Água Extravascular Pulmonar , Hemodinâmica , Humanos , Recém-Nascido , Período Pós-Operatório , Estudos Retrospectivos , Volume Sistólico , Termodiluição/instrumentação , Termodiluição/métodos , Resultado do TratamentoRESUMO
PURPOSE: Iatrogenic atrial septal defect (IASD) after catheter ablation (CA) for atrial fibrillation (AF) due to transseptal puncture (TSP) can occur. The aim of this prospective study was to describe the incidence of IASD and to detect any cerebrovascular accident (CVA) after radiofrequency (RF) and cryoballoon (CB) CA. METHODS: Between July 2014 and September 2016, 94 patients (pts) (RF; 48, CB; 46, 30 (31.9%) women, mean age = 60 ± 9.7 years) with paroxysmal AF were enrolled who underwent CA procedure for the first time. During RF ablation a single (n = 30, 62.5%) or double (n = 18, 37.5%) TSP was performed. Transoesophageal echocardiography before the procedure and at the 3-month and 12-month follow-up (FU) was accomplished. During the FU period, we evaluated the occurrence of any postprocedural CVA. RESULTS: At the 3-month FU, IASD was detected in 17/94 (18.1%) pts; in 9/48 (18.8%) pts in the RF while in 8/46 (17.4%) pts in the CB group (p = 0.866), all of them with left-to-right shunt. In the RF group, 6/30 (20%) pts with a single TSP while 3/18 (16.7%) pts in the double TSP group had IASD (p = 0.780). 14/17 (82.4%) IASDs showed high spontaneous closure rate at the 12-month FU. None of the pts died or suffered from CVA. CONCLUSION: Persistent IASD can occur rather frequently following AF CA. No significant difference was observed between the RF and CB techniques concerning the presence of IASD at 3-month. IASDs showed a high spontaneous closure rate. No cerebral thromboembolic event was observed in the 12-month FU period.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Criocirurgia/efeitos adversos , Comunicação Interatrial/etiologia , Doença Iatrogênica , Ecocardiografia Transesofagiana , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
BACKGROUND: Our aim was to investigate postoperative complications and mortality after administration of aprotinin compared to tranexamic acid in an unselected, consecutive cohort. METHODS: Perioperative data from consecutive cardiac surgery patients were prospectively collected between September 2005 and June 2006 in a university-affiliated clinic (n = 1188). During the first 5 mo, 596 patients received aprotinin (Group A); in the next 5 mo, 592 patients were treated with tranexamic acid (Group T). Except for antifibrinolytic therapy, the anesthetic and surgical protocols remained unchanged. RESULTS: The pre- and intraoperative variables were comparable between the treatment groups. Postoperatively, a significantly higher incidence of seizures was found in Group T (4.6% vs 1.2%, P < 0.001). This difference was also significant in the primary valve surgery and the high risk surgery subgroups (7.9% vs 1.2%, P = 0.003; 7.3% vs 2.4%, P = 0.035, respectively). Persistent atrial fibrillation (7.9% vs 2.3%, P = 0.020) and renal failure (9.7% vs 1.7%, P = 0.002) were also more common in Group T, in the primary valve surgery subgroup. On the contrary, among primary coronary artery bypass surgery patients, there were more acute myocardial infarctions and renal dysfunction in Group A (5.8% vs 2.0%, P = 0.027; 22.5% vs 15.2%, P = 0.036, respectively). The 1-yr mortality was significantly higher after aprotinin treatment in the high risk surgery group (17.7% vs 9.8%, P = 0.034). CONCLUSION: Both antifibrinolytic drugs bear the risk of adverse outcome depending on the type of cardiac surgery. Administration of aprotinin should be avoided in coronary artery bypass graft and high risk patients, whereas administration of tranexamic acid is not recommended in valve surgery.
Assuntos
Antifibrinolíticos/efeitos adversos , Aprotinina/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ácido Tranexâmico/efeitos adversos , Adulto , Idoso , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte de Artéria Coronária , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Insuficiência Renal/induzido quimicamente , Risco , Convulsões/induzido quimicamenteRESUMO
OBJECTIVE: To explore the long-term effect of anxiety and depression on outcome after cardiac surgery. To date, the relationship between psychosocial factors and future cardiac events has been investigated mainly in population-based studies, in patients after cardiac catheterization or myocardial infarction. METHODS: In total, 180 patients who underwent cardiac surgery using cardiopulmonary bypass were prospectively studied and followed up for 4 years. Anxiety (Spielberger State-Trait Anxiety Inventory, STAI-S/STAI-T), depression (Beck Depression Inventory, BDI), living alone, and education level along with clinical risk factors and perioperative characteristics were assessed. Psychological self-report questionnaires were completed preoperatively and 6, 12, 24, 36, and 48 months after discharge. Clinical end-points were mortality and cardiac events requiring hospitalization during follow-up. RESULTS: Average preoperative STAI-T score was 44.6 +/- 10. Kaplan-Meier analysis showed a significant effect of preoperative STAI-T >45 points (p = .008) on mortality. In multivariate models, postoperative congestive heart failure (OR: 10.8; 95% confidence interval [CI]: 2.9-40.1; p = .009) and preoperative STAI-T (score OR: 1.07; 95% CI: 1.01-1.15; p = .05) were independently associated with mortality. The occurrence of cardiovascular hospitalization was independently associated with postoperative intensive care unit days (OR: 1.41; 95% CI: 1.01-1.96; p = .045) and post discharge 6th month STAI-T (OR: 1.06; 95% CI:1.01-1.13; p = .03). CONCLUSIONS: The results of the present study suggest that the assessment of psychosocial factors, particularly the ongoing assessment of anxiety, could help in risk stratification and identification of patients at risk of mortality and cardiovascular morbidity after cardiac surgery.
Assuntos
Ansiedade , Ponte de Artéria Coronária/mortalidade , Depressão , Idoso , Ponte Cardiopulmonar , Doença da Artéria Coronariana/cirurgia , Feminino , Seguimentos , Valvas Cardíacas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Prognóstico , Estudos Prospectivos , Medição de RiscoRESUMO
INTRODUCTION: The aim of this study was to investigate the role of the insulin and glucose content of the maintenance fluid in influencing the outcomes of pediatric patients undergoing heart surgery. METHODS: A total of 2063 consecutive pediatric patients undergoing cardiac surgery were screened between 2003 and 2008. A dextrose and an insulin propensity-matched group were constructed. In the dextrose model, 5% and 10% dextrose maintenance infusions were compared below 20 kg of weight. RESULTS: A total of 171 and 298 pairs of patients were matched in the insulin and glucose model, respectively. Mortality was lower in the insulin group (12.9% vs. 7%, p = 0.049). The insulin group had longer intensive care unit (ICU) stay [days, 10.9 (5.8-18.4) vs. 13.7 (8.2-21), p = 0.003], hospital stay [days, 19.8 (13.6-26.6) vs. 22.7 (17.6-29.7), p < 0.01], duration of mechanical ventilation [hours, 67 (19-140) vs. 107 (45-176), p = 0.006], and the incidence of severe infections (18.1% vs. 28.7%, p = 0.01) and dialysis (11.7% vs. 24%, p = 0.001) was higher. In the dextrose model, the incidence of pulmonary complications (13.09% vs. 22.5%, p < 0.01), low cardiac output (17.11% vs. 30.9%, p < 0.01), and severe infections (10.07% vs. 20.5%, p < 0.01) was higher, and the duration of the hospital stay [days, 16.4 (13.1-21.6) vs. 18.1 (13.8-24.6), p < 0.01] was longer in the 10% dextrose group. CONCLUSIONS: Insulin treatment appeared to decrease mortality, and lower glucose content was associated with lower occurrence of adverse events.
RESUMO
BACKGROUND: The pediatric-modified Risk, Injury, Failure and Loss, and End-Stage (pRIFLE) criteria and a different but conceptually similar system termed Acute Kidney Injury Network (AKIN) were created to standardize the definition of acute kidney injury (AKI) in children. Kidney Disease: Improving Global Outcomes (KDIGO) currently recommends a combination of AKIN and pRIFLE in AKI. This study aimed to compare the three classifications for predicting AKI in pediatric patients undergoing cardiac operations. METHODS: We analyzed the prospectively collected data of 1,489 consecutive pediatric patients undergoing cardiac operations between January 2004 and December 2008. AKI presence and severity was assessed for each classification using the change in serum creatinine and estimated creatinine clearance levels calculated by the Schwartz equation. RESULTS: AKI was present in 285 (20%), 481 (34%), and 409 (29%) patients according to the AKIN, pRIFLE, and KDIGO systems, respectively. The KDIGO classification categorized 121 patients (8%) who were placed in the AKIN 0 category, whereas the pRIFLE system categorized 74 (5%) in KDIGO 0 and 200 (14%) in AKIN 0 stages as having an AKI. The overall mortality rate was 3.9%. The KDIGO stage III (odds ratio [OR], 18.8; 95% confidence interval [CI], 9.6 to 36.6, p < 0.001), the AKIN stage III (OR, 38.3; 95% CI, 20.6 to 70.9, p < 0.001), and pRIFLE failure group (OR, 13.6, 95% CI, 7 to 26.3; p < 0.001) were associated with increased mortality. CONCLUSIONS: The pRIFLE system was the most sensitive test in detecting AKI, and this was especially so in the infant age group and also in the early identification of AKI in low-risk patients. The AKIN system was more specific and detected mostly high-risk patients across all age groups. The KDIGO classification system fell between pRIFLE and AKIN in performance. All three had increasing severity of AKI associated with mortality.
Assuntos
Injúria Renal Aguda/classificação , Injúria Renal Aguda/mortalidade , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Causas de Morte , Mortalidade Hospitalar/tendências , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/terapia , Adolescente , Fatores Etários , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Criança , Pré-Escolar , Estudos de Coortes , Intervalos de Confiança , Feminino , Seguimentos , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Testes de Função Renal , Masculino , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Diálise Renal/métodos , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The objective of this study was to identify the postoperative risk factors associated with the conversion of colonization to postoperative infection in pediatric patients undergoing cardiac surgery. METHODS: Following approval from the Institutional Review Board, patient demographics, co-morbidities, surgery details, transfusion requirements, inotropic infusions, laboratory parameters and positive microbial results were recorded during the hospital stay, and the patients were divided into two groups: patients with clinical signs of infection and patients with only positive cultures but without infection during the postoperative period. Using propensity scores, 141 patients with infection were matched to 141 patients with positive microbial cultures but without signs of infection. Our database consisted of 1665 consecutive pediatric patients who underwent cardiac surgery between January 2004 and December 2008 at a single center. The association between the patient group with infection and the group with colonization was analyzed after propensity score matching of the perioperative variables. RESULTS: 179 patients (9.3%) had infection, and 253 patients (15.2%) had colonization. The occurrence of Gram-positive species was significantly greater in the colonization group (p=0.004). The C-reactive protein levels on the first and second postoperative days were significantly greater in the infection group (p=0.02 and p=0.05, respectively). The sum of all the positive cultures obtained during the postoperative period was greater in the infection group compared to the colonization group (p=0.02). The length of the intensive care unit stay (p<0.001) was significantly longer in the infection group compared to the control group. CONCLUSIONS: Based on our results, we uncovered independent relationships between the conversion of colonization to infection regarding positive S. aureus and bloodstream results, as well as significant differences between the two groups regarding postoperative C-reactive protein levels and white blood cell counts.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Portador Sadio/microbiologia , Infecção Hospitalar/microbiologia , Infecção da Ferida Cirúrgica/microbiologia , Bactérias/isolamento & purificação , Infecções Relacionadas a Cateter/etiologia , Infecções Relacionadas a Cateter/microbiologia , Pré-Escolar , Cuidados Críticos , Infecção Hospitalar/etiologia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pontuação de Propensão , Estudos Prospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/etiologiaRESUMO
BACKGROUND: The RIFLE (risk, injury, failure, loss, and end-stage renal disease) classification system was developed to standardize the definition of acute kidney injury (AKI) in adults. We hypothesized that AKI was associated with increased mortality and morbidity. METHODS: Acute kidney injury was defined as a decrease in the amount of estimated creatinine clearance based on pediatric-modified RIFLE (pRIFLE) criteria. Using propensity score analysis, 325 patients who had AKI were matched to 325 patients who did not have AKI from a database of 1,510 consecutive pediatric patients who underwent cardiac surgery between January 2004 and December 2008 at a single center. The association between AKI and outcome was analyzed after propensity score matching of perioperative variables. RESULTS: Four hundred eighty-one patients (31.9%) had AKI according to the RIFLE categories. Of those 1,510, 173 (11.5%) reached pRIFLE criteria for risk; 26 (1.7%) reached the criteria for injury; and 282 (18.7%) reached the criteria for failure. Fifty-five patients (3.6%) died. The 2 matched groups were well balanced in terms of measured perioperative variables. Mortality rate was 5.2% in the AKI and 2.5% in the matched control group (p=0.09). Occurrence of low cardiac output syndrome (p=0.002), need for dialysis (p<0.001), and infection (p=0.03) were significantly higher, and duration of mechanical ventilation (p<0.001) and length of intensive care unit stay (p<0.001) were significantly longer compared with the matched control group. CONCLUSIONS: Acute kidney injury was independently associated with an increased occurrence of postoperative complications but not with mortality after pediatric cardiac surgery.
Assuntos
Injúria Renal Aguda/etiologia , Recursos em Saúde/estatística & dados numéricos , Cardiopatias Congênitas/cirurgia , Complicações Pós-Operatórias/etiologia , Injúria Renal Aguda/mortalidade , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/mortalidade , Humanos , Lactente , Recém-Nascido , Masculino , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Pontuação de Propensão , Terapia de Substituição Renal/estatística & dados numéricos , Taxa de Sobrevida , Revisão da Utilização de Recursos de SaúdeRESUMO
OBJECTIVE: Tranexamic acid (TXA) and É-aminocaproic acid (EACA) are used for antifibrinolytic therapy in cardiac surgery, although data directly comparing their blood sparing effect and their side effects, especially in paediatric cardiac surgical patients, are still missing. METHODS: We analysed perioperative data of 234 paediatric patients weighing less than 20 kg undergoing cardiac surgery. In a 5-month period, all patients (n=114) received TXA (group TXA). During a second 5-month period, all patients (n=120) were treated with EACA (group EACA). Primary outcome was blood loss at 24h postoperatively; secondary outcome criteria were transfusion requirement, rate of revision for bleeding, postoperative complications and in-hospital mortality. RESULTS: All descriptive and intra-operative parameters were well comparable. There was no evidence for a difference in blood loss at 24h postoperatively (TXA 21 ml kg(-1) (14-38) (median (interquartile range)) vs EACA 29 ml kg(-1) (14-40), p=0.242), rate of re-operation for bleeding (TXA 9.6% vs EACA 8.3%, p=0.725) and transfusion of blood products. The incidence of postoperative complications such as seizures (TXA 3.5% vs EACA 0.8%, p=0.203) and other neurological complications (TXA 2.6% vs EACA 1.7%, p=0.677), renal injury (TXA 9.6% vs EACA 13.3%, p=0.378), renal failure (TXA 1.8% vs EACA 4.2%, p=0.447), low cardiac output syndrome (TXA 12.3% vs EACA 10.8%, p=0.729), and vascular thrombosis (TXA 4.4% vs EACA 5.0%, p=0.824), as well as the in-hospital mortality (TXA 2.6% vs EACA 3.3%, p>0.999) did not show any statistically significant difference. CONCLUSIONS: TXA and EACA are well comparable in their effect on perioperative blood loss as well as in major clinical outcome criteria. Although the fourfold risk for seizures using TXA was not significant, we currently use EACA in paediatric cardiac surgery.
Assuntos
Ácido Aminocaproico/uso terapêutico , Antifibrinolíticos/uso terapêutico , Procedimentos Cirúrgicos Cardíacos/métodos , Hemorragia Pós-Operatória/prevenção & controle , Ácido Tranexâmico/uso terapêutico , Ácido Aminocaproico/efeitos adversos , Antifibrinolíticos/efeitos adversos , Transfusão de Sangue , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar , Estudos de Coortes , Avaliação de Medicamentos/métodos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Cuidados Pós-Operatórios/métodos , Hemorragia Pós-Operatória/cirurgia , Reoperação/estatística & dados numéricos , Convulsões/induzido quimicamente , Ácido Tranexâmico/efeitos adversos , Resultado do TratamentoRESUMO
OBJECTIVE: Recently, the safety of aprotinin administration during open-heart surgery has been debated. The aim of the study was to compare the blood sparing effect and the side effects of aprotinin and tranexamic acid in paediatric cardiac surgery patients. METHODS: Perioperative data of 199 consecutive patients weighing less than 20kg undergoing open-heart cardiac surgery were prospectively collected between September 2005 and June 2006. During the first 5 months, 85 patients received aprotinin (group A); in the next 5 months, 114 patients were treated with tranexamic acid (group T). Except for antifibrinolytic therapy, the anaesthesiological and surgical protocols remained unchanged. Postoperative complications and in-hospital and 1-year mortality were considered as outcome parameters. RESULTS: The descriptive parameters and the intraoperative parameters were well comparable in the two groups. The blood loss was significantly lower in group A compared to group T at 6h [55 (35-82.5) vs 70 (45-100)ml, p=0.031], but not at 12 and 24h after operation. The incidence [9 (11%) vs 25 (22%), p=0.035] and the amount of red blood cell transfusion during the first 24h after surgery were also significantly lower in group A (0.1+/-0.4 vs 0.3+/-0.6 unit, p=0.036). There were significantly less rethoracotomies in group A [2 (2.4%) vs 11 (9.6%), p=0.039]. We found no difference in the incidence of the postoperative complications and in-hospital and 1-year mortality. There was a tendency for a higher incidence of seizures in group T [4 (3.5%) vs 0 (0%), p=0.14]. CONCLUSIONS: Aprotinin administration bears no additional risks compared to tranexamic acid and it has a stronger blood sparing effect in paediatric cardiac surgery. There were fewer rethoracotomies and less postoperative red blood cell transfusion in patients who received aprotinin.
Assuntos
Antifibrinolíticos/uso terapêutico , Aprotinina/uso terapêutico , Cardiopatias Congênitas/cirurgia , Hemorragia Pós-Operatória/prevenção & controle , Ácido Tranexâmico/uso terapêutico , Antifibrinolíticos/efeitos adversos , Aprotinina/efeitos adversos , Transfusão de Componentes Sanguíneos , Perda Sanguínea Cirúrgica , Esquema de Medicação , Feminino , Hemostasia Cirúrgica/métodos , Humanos , Lactente , Recém-Nascido , Cuidados Intraoperatórios/métodos , Masculino , Complicações Pós-Operatórias , Estudos Prospectivos , Reoperação , Ácido Tranexâmico/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Blood transfusion in adults is associated with increased mortality and morbidity after cardiac operations. The aim of this study was to identify the main predictors of blood transfusion and explore the relationship between blood transfusion and adverse outcomes in a pediatric population. METHODS: We retrospectively analyzed a prospectively collected database (January 2002 to December 2003) of 657 consecutive pediatric patients undergoing open heart procedures in a tertiary pediatric cardiac center. Risk models were calculated for each blood product and for the total amount of blood transfused during the operation and in the first 24 hours. Postoperative adverse events were investigated after propensity score adjustment. RESULTS: During the postoperative period, 30 patients (4.6%) died, 80 (12.2%) sustained nonvascular pulmonary complications, and 113 (17.2%) had infection. The risk model for the total amount of blood transfusion included weight, preoperative creatinine clearance, preoperative mechanical ventilation, duration of operation and cross-clamp, surgeon, delayed chest closure, inotropic dose, and nitric oxide administration. Univariate analyses demonstrated significant associations between blood transfusion and occurrence of every complication except of neurologic events. After adjustment for propensity score and disease severity, the total amount of blood transfusion was independently associated with an increased risk for infections (odds ratio, 1.01; 95% confidence interval, 1.002 to 1.02; p = 0.01). Transfusion of platelets was associated with lower incidence of nonvascular pulmonary complications (odds ratio, 0.89; 95% confidence interval, 0.79 to 0.99; p = 0.049). CONCLUSIONS: The amount of blood transfusion is independently associated with infections but not with mortality.
Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Causas de Morte , Cardiopatias Congênitas/mortalidade , Mortalidade Hospitalar/tendências , Reação Transfusional , Fatores Etários , Análise de Variância , Transfusão de Sangue/métodos , Transfusão de Sangue/mortalidade , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/métodos , Pré-Escolar , Estudos de Coortes , Intervalos de Confiança , Transfusão de Eritrócitos/efeitos adversos , Feminino , Seguimentos , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/cirurgia , Humanos , Incidência , Lactente , Recém-Nascido , Modelos Lineares , Masculino , Razão de Chances , Transfusão de Plaquetas/efeitos adversos , Pneumonia/diagnóstico , Pneumonia/mortalidade , Cuidados Pós-Operatórios/efeitos adversos , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Análise de Sobrevida , Transplante AutólogoRESUMO
BACKGROUND: Aprotinin is a potent antifibrinolytic drug, which reduces postoperative bleeding and transfusion requirements. Recently, two observational studies reported increased incidence of renal dysfunction after aprotinin use in adults. Therefore, the aim of the study was to investigate the safety of aprotinin use in pediatric cardiac surgery patients. METHODS: Data were prospectively and consecutively collected from 657 pediatric patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The database was assessed with regard to a possible relationship between aprotinin administration and dialysis and between aprotinin and postoperative renal dysfunction [defined as 25% decrease in the creatinine clearance (Ccr) compared with the preoperative value] by propensity-score adjustment and multivariable methods. RESULTS: The incidence of dialysis (9.6% vs 4.1%; P = 0.005) and renal dysfunction (26.3% vs 16.1%; P = 0.019) was higher in patients who received aprotinin; however, propensity adjusted risk ratios were not significant [odds ratio (OR) of dialysis: 1.22; 95% confidence interval (CI) 0.46-3.22; OR of renal dysfunction 1.26; 95% CI: 0.66-1.92]. Aprotinin significantly reduced blood loss in the first postoperative 24 h. The main contributors of renal dysfunction were CPB duration, cumulative inotropic support, age, preoperative Ccr, amount of transfusion and pulmonary hypertension. CONCLUSIONS: Despite the higher incidences of renal dysfunction and failure in the aprotinin group, an independent role of the drug in the development of renal dysfunction or dialysis could not be demonstrated in pediatric cardiac patients undergoing CPB.
Assuntos
Aprotinina/uso terapêutico , Perda Sanguínea Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos Cardiovasculares , Hemostáticos/uso terapêutico , Insuficiência Renal/etiologia , Aprotinina/efeitos adversos , Ponte Cardiopulmonar , Pré-Escolar , Hemostáticos/efeitos adversos , Humanos , Lactente , Complicações Pós-Operatórias , Estudos Prospectivos , Diálise RenalRESUMO
BACKGROUND: Natriuretic peptide levels are associated with cardiac output and ventricular function. We hypothesized that concomitant measurement of the peptide fragments and the hemodynamic parameters could elucidate the associations of these parameters after pediatric cardiac surgery. METHODS: After approval of the institutional review board and parents' informed consent, we investigated the clinical data of eight neonates undergoing correction of transposition of the great arteries. We measured the level of N-terminal fragments of prohormones of atrial and brain natriuretic peptides (NT-proANP, NT-proBNP) preoperatively, postoperatively and 12, 24, 48, and 72 h after arrival in the intensive care unit. The hemodynamic status was assessed by transpulmonary thermodilution at the same time points. Creatinine and other laboratory values were analyzed in the first 48 h postoperatively. RESULTS: NT-proBNP levels were inversely correlated with cardiac index (CI, r = -0.47, P = 0.030), stroke volume index (r = -0.65, P = 0.005), and global end-diastolic volume index (GEDI; r = -0.63, P = 0.011). There was strong inverse correlation between the change of NT-proBNP levels and the change of CI between two consecutive measurements during the postoperative period (r = -0.79, P = 0.001). The NT-proBNP level 12 h after surgery was strongly correlated with the creatinine level of the postoperative 24th hour (r = 0.81, P = 0.014). CONCLUSIONS: NT-proBNP correlated with the hemodynamic parameters and with the severity of renal dysfunction. Therefore, NT-proBNP is a reliable indicator of the circulatory state and the severity of a low output syndrome after arterial switch operation in neonates.