Shock--manifestation of pulmonary atresia with aorto-pulmonary collaterals and single ventricle physiology in a 2-day neonate.

BACKGROUND: The combination of pulmonary valve atresia and ventricular septal defect accounts for about 2% of cases of congenital heart disease. Most of the cases have intracardiac anatomy of Tetralogy Fallot and present with cyanosis in neonatal age. OBJECTIVES: To report a case of a newborn with rare combination of pulmonary atresia, ventricular septal defect and single ventricle physiology presenting with shock very early following birth. METHODS AND RESULTS: We describe a newborn infant who developed shock with severe metabolic acidosis and respiratory distress several hours following birth. Cardiac ultrasound showed pulmonary atresia and ventricular septal defect with single ventricle physiology. Cardiac cathetrisation revealed major aorto-pulmonary collaterals with an excessive pulmonary blood flow. Resuscitative measures resulted in hemodynamic stability. However, due to unfavorable prognosis, a decision not to undertake surgical palliation was made. Withdrawal of intensive care led to rapid demise of the patient. CONCLUSIONS: We report a case of a newborn with pulmonary atresia, ventricular septal defect and single ventricle physiology in whom an excessive flow through major aorto-pulmonary collaterals led to shock and death very early following birth (Fig. 1, Ref. 5). Full Text (Free, PDF) www.bmj.sk.

Procalcitonin, neopterin and C-reactive protein after pediatric cardiac surgery with cardiopulmonary bypass.

BACKGROUND: Kinetics of activation of newly introduced inflammatory markers is of particular value in their use in postoperative setting after pediatric cardiac surgery. OBJECTIVE: To assess the influence of cardiopulmonary bypass (CPB) on activation of inflammatory markers. METHODS: Procalcitonin, neopterin and C-reactive protein (CRP) blood levels were measured before, on day 1 and day 2 after surgery in 152 pediatric patients undergoing cardiac surgery with CPB. All patients had infection-free postoperative course. RESULTS: Procalcitonin blood levels increased from 0.08 (0.001-0.19) ng/mL before surgery to 0.79 (0.13-3.5) ng/mL on day 1 (p < 0.001) and 0.52 (0.07-2.7) ng/mL on day 2 (p < 0.001) after surgery. Procalcitonin levels on day 1 correlated with CPB duration, cross-clamping time and use of aprotinin. Neopterin values increased from 8.4 (4.4-32) nmol/L before surgery to 16.1 (6.8-37.6) nmol/L on day 1 (p < 0.001) and 10.9 (5.3-31.1) nmol/L on day 2 (p < 0.001) after surgery. Neopterin levels on day 1 correlated negatively with age, lowest esophageal temperature and use of aprotinin; and positively with circulatory arrest, length of stay and use of modified ultrafiltration. CRP values increased from 4.7 (2.7-9.6) mg/L before surgery to 38.8 (13-73.5) mg/L (p < 0.001) on day 1 and 38.3 (15-88) mg/L (p < 0.001) on day 2 after surgery. CRP levels correlated positively with age at surgery, use of aprotinin and lowest esophageal temperature; and negatively with circulatory arrest and modified ultrafiltration. CONCLUSIONS: Procalcitonin and neopterin levels peaked on day 1, CRP levels remained elevated during first two postoperative days. Neopterin and CRP had age dependent kinetics (Tab. 2, Fig. 2, Ref. 18). Full Text (Free, PDF) www.bmj.sk.

Immunologic status in pediatric cardiosurgical patients with chylothorax.

OBJECTIVE: The impact of lymphocyte and immunoglobulin loss on immunologic status has not been extensively studied in children with chylothorax. The purpose of this study was to evaluate immunologic profile of pediatric cardiosurgical patients who developed infection while suffering from prolonged postoperative chylothorax. METHODS: We retrospectively reviewed immunologic findings in 16 pediatric cardiac patients with post-operative chylothorax persisting ?7 days. Patients were on total parenteral nutrition, received colloides for replacement of chylous losses, and antibiotics and/or antimycotics for treatment of infection. Immunologic evaluation included immunoglobulin levels, cellular immunity, and phagocytic activity. For every parameter z-score was calculated according to age-dependent nomograms and t-test was used to compare z-score distribution with normal distribution. RESULTS: The immunoglobulin (IgG, IgM, and IgA) levels did not significantly differ from normal values, although 25% patients had IgG levels below normal range. The relative and absolute counts of peripheral blood lymphocytes were lower (p < 0.001) than normal values. Absolute numbers of blood B-lymphocytes (CD19+), T-lymphocytes (CD3+), helper/inducer T-cells (CD4+), and suppressor/cytotoxic T-cells (CD8+) were also below normal range (p < 0.001); however, their relative percentages and a CD4+/CD8+ ratio were within normal limits. The percentage and absolute number of natural killer cells (CD16+), phagocytic and metabolic activity of polymorphonuclear leukocytes did not differ from normal values. CONCLUSIONS: Persisting chylothorax results in B-cell and T-cell lymphopenia with proportional decline of CD4+ and CD8+ cells. Hypogammaglobulinemia observed in other studies has not been detected in this series probably due to administered plasma. Effects of these immunologic alterations on development of infection are unknown (Tab. 2, Ref. 13).

Neonates with left-sided obstructive heart disease: clinical manifestation and management at primary care hospitals.

BACKGROUND: In neonates, left-sided obstructive heart defects are critical diseases requiring early recognition, initial stabilization, and transfer to Cardiac Center. OBJECTIVES: To assess management of these neonates in primary care hospitals. METHODS: Retrospective analysis of medical records of neonates admitted to Cardiac Intensive Care Unit in whom diagnosis of left-sided obstructive heart defect was established. RESULTS: During 8-year period records of 117 patients were evaluated. Of those, 83 had hypoplastic left heart syndrome, 13 aortic stenosis, 12 coarctation of aorta, and 9 interruption of aortic arch. In 13 (11%) patients diagnosis of heart defect was established prenatally, other neonates presented postnatally with heart failure (28.2%), shock (65.4%) or severe cyanosis (4.8%). Continuous infusion of PGE1 and dopamine was administered in 84.6% and 30.8% patients, respectively. Thirty-two (30.8%) patients were mechanically ventilated and 36 (34.6%) received sodium bicarbonate. In referring hospitals the heart defect was most often diagnosed using echocardiography and diagnosis was established accurately in 55% patients. CONCLUSION: The study showed that in primary care hospitals neonates with known or suspected left-sided obstructive heart disease need more aggressive resuscitative measures than those used in this patient series. Prenatal diagnosis rate of these heart defects is very low (Tab. 3, Fig. 1, Ref 8). Full Text (Free, PDF) www.bmj.sk.

Thyroid hormone metabolism in pediatric cardiac patients treated by continuous povidone-iodine irrigation for deep sternal wound infection.

OBJECTIVE: The purpose of this study was to assess the influence of povidone-iodine mediastinal irrigation used for the treatment of deep sternal wound infection (DSWI) on thyroid function. METHODS: Thyroid function was studied in 18 pediatric cardiac patients treated with continuous povidone-iodine irrigation for DSWI. The median age of patients was 8 months (18 days-5.3 years). Serum concentrations of total triiodothyronine (TT3), total thyroxine (TT4), free triiodothyronine (FT3), free thyroxine (FT4), thyroid-stimulating hormone (TSH), reverse triiodothyronine (rT3) and thyroxine-binding globulin (TBG) were measured at three time points: (a) prior to mediastinal reexploration (before povidone-iodine exposure); (b) immediately after discontinuation of povidone-iodine irrigation; (c) 2 weeks after discontinuation of mediastinal irrigation. Urinary iodine excretion was examined on the last day of povidone-iodine exposure. RESULTS: Prior to the mediastinal reexploration, the median TT3 and TT4 levels were below the normal range, then increased significantly to concentrations within the normal range. The median serum FT3 levels were within the normal range throughout the observation period, though a significant increase of FT3 levels was observed after discontinuation of irrigation. The median serum FT4 concentrations were within the normal range prior to irrigation and did not change significantly. The median rT3 levels were within the normal range, close to upper normal limit. The median TBG levels were within the normal range throughout the observation period, though a significant increase of TBG levels was observed during the period of mediastinal irrigation. The median TSH level was within the normal range prior to mediastinal irrigation and did not change significantly. Urinary iodine concentrations in infants with povidone-iodine irrigation were significantly higher 6700 microg/l (range, 1600-15000 microg/l) than in the group of 53 healthy infants 200 microg/l (range, 20-780 microg/l, P<0,001). CONCLUSIONS: Our data showed that the use of povidone-iodine irrigation in the patients with DSWI has not lead to any significant alteration in thyroid function within the study period.

[High-frequency pressure ventilation with high positive end-expiratory pressure in the treatment of respiratory failure in neonates]. / Vysokofrekvencná tlakovo riadená ventilácia s vysokým pozitívnym koncovoexspiracným tlakom v liecbe respiracného zlyhania novorodencov.

The authors present results of group of 13 neonates treated with high frequency positive pressure ventilation (HFPPV) with high positive end-expiratory pressure (PEEP) for severe respiratory failure. The ventilatory protocol was based on the following principles: a) higher mean airway pressure (MAP) to achieve adequate oxygenation, b) MAP titrated mainly with PEEP, c) fraction of inspired oxygen (FiO2) below 0.6, d) small tidal volumes 3-6 ml/kg, e) ventilatory rates to achieve normocapnia in newborns with persistent pulmonary hypertension and to allow permissive hypercapnia in others. During HFPPV, the maximum values for respiratory rate, PEEP, MAP and peak inspiratory pressures (PIP), the incidence of airleak and the need for inotropic support were recorded. The values for arterial partial pressure of oxygen (paO2), FiO2, paO2/FiO2 and MAP during conventional ventilation and 30 minutes after initiation of HFPPV were statistically analyzed. paO2 increased from 8.0 kPa (3.3-10.4) to 11.8 kPa (7.3-16.2, p < 0.001) and paO2 (torr)/FiO2 increased from 62.2 (24.7-101.2) to 157.5 (62.2-275.2, p < 0.001) 30 minutes after institution of HFPPV when MAP was increased from 11.8 cmH2O (9-13.8,) to 17.2 H2O (14.8-22.2) p < 0.001. This allowed turning down FiO2 from 1 (0.6-1) to 0.6 (0.4-1 p < 0.001). Maximal ventilatory rates used were in average 60/min (50-105), PEEP 8 cmH2O (6-10), PIP 30 cmH2O (26-45), MAP 18.8 cmH2O (14.8-22.2). Air leak did not occur in any patient. Catecholamines were used in 8 patients. The duration of ventilatory support lasted in average 6 days (2-18). All patients were successfully extubated. 5 of them required nasal continuous positive airway pressure (14 hours--7 days). (Tab. 3, Fig. 3, Ref. 19.)

[Peritoneal dialysis in children after cardiac surgery]. / Peritoneálna dialýza u detí po kardiochirurgických operáciách.

The authors analyse their experience with the use of peritoneal dialysis (PD) in children with acute renal failure after cardiac surgery. From 1995 through 1998, 1246 children were operated in Pediatric Cardiocenter 38 of them developed acute renal failure and required peritoneal dialysis. Indications for PD were oliguria, anuria, hyperkalemia and fluid overload with generalized tissue oedema. PD was instituted at mean 33.9 (3-132) hours after surgery and lasted mean 53.7 (6-264) hours. None of the patients developed peritoneal infection. Hyperglycaemia developed in 8 patients and was treated with continuous insulin infusion. 5 patients required catheter reposition or reinsertion due to inadequate fluid removal and 1 patient required another renal replacement therapy. 22 (57.9%) patients died due to intractable low cardiac output. 16 survivors recovered their renal functions. In a long-term follow-up, 7 patients had no signs of significant renal dysfunction. In 4 patients, mild elevation of N-acetyl-beta-D-glukozaminidase indicates mild proximal tubular dysfunction. These findings together with aminoaciduria in 5 patients will require a further follow-up. (Tab. 2, Fig. 1, Ref. 16.)